Professional Provider Office Manual 2027

Reference Section - Updated 1/1/2027
Section 1: Network Overview - Updated 1/1/2027
Section 2: Network Participation - Updated 1/1/2027
Section 3: Member Engagement
Section 4: Medical Management - Updated 1/1/2027
Section 5: Billing and Reimbursement Guidelines - Updated 1/1/2027
Section 5.1 General Billing - Updated 1/1/2027
Section 5.2 Acupuncture
Section 5.3 After Hours Care
Section 5.4 Ambulance Transport Benefit
Section 5.5 Anesthesia - Updated 1/1/2027
Section 5.6 Autism
Section 5.7 Behavioral Health - Updated 1/1/2027
Section 5.8 Chiropractic and Physical Medicine Services - Updated 1/1/2027
Section 5.9 Code Editing
Section 5.10 Concierge Medicine
Section 5.11 Dialysis - Updated 1/1/2027
Section 5.12 Dietitian
Section 5.13 Drug Screening Assays
Section 5.14 Durable Medical Equipment and Supplies - Updated 1/1/2027
Section 5.15 Evaluation and Management Services
Section 5.16 Home Health Agency - Updated 1/1/2027
Section 5.17 Incident to
Section 5.18 Infusion Therapy
Section 5.19 In-Office Procedures
Section 5.20 Intra-operative Monitoring Services
Section 5.21 Laboratory - Updated 1/1/2027
Section 5.22 Maternity Care and Delivery - Updated 1/1/2027
Section 5.23 Medication Substitution
Section 5.24 Modifiers - Updated 1/1/2027
Section 5.25 Multiple Procedures
Section 5.26 Multiple Service Reduction for Diagnostic Imaging Services
Section 5.27 Nasal Endoscopy Procedures
Section 5.28 Nucleic Acid Probe Services
Section 5.29 Nurse Practitioner and Physician Assistant Services
Section 5.30 Ordering/Referring Provider Requirements
Section 5.31 Pass-through Billing and Billing for Services Not Rendered
Section 5.32 Place of Service - Updated 1/1/2027
Section 5.33 Provider Based Billing
Section 5.34 Rural Health Clinic and Federally Qualified Health Clinic
Section 5.35 Sleep Study
Section 5.36 Specialty Pharmacy
Section 5.37 Telemedicine/Telehealth
Section 5.38 Urgent Care Centers
Section 5.39 Colonoscopy and Upper Gastrointestinal Endoscopy MPR
Section 5.40 Pharmaceutical Waste
Section 5.41 Mass Immunizers
Section 5.42 Digital Health
Section 5.43 Fertility Preservation Services
Section 5.44 Medical Record Documentation
Section 5.45 Dental Billing
Section 5.46 Speech Therapy
Section 5.47 Ambulatory Surgery Centers
Section 5.48 HIV Pre-exposure Prophylaxis - Updated 1/1/2027
Section 5.49 Breast Feeding and Lactation Services
Section 5.50 Clinical Trials
Section 5.51 Access to Information and Medical Records - New 1/1/2027
Section 6: Other Coverage - Updated 1/1/2027
Section 7: Claims Submission - Updated 1/1/2027
Section 8: Claims Resolutions - Updated 1/1/2027
Appendix I: Online Resources - Updated 1/1/2027
Appendix II: Forms - Updated 1/1/2027
Appendix III: Definitions - Updated 1/1/2027
Appendix IV: Taxonomy Codes - New 1/1/2027

Printable PDF of Entire Manual - Updated 1/1/2027