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Reimbursement Methodology for Non-Participating Providers

Policy No: 135
Originally Created: 01/01/2018
Section: Administrative
Last Reviewed: 12/01/2023
Last Revised: 12/01/2023
Approved: 12/14/2023
Effective: 01/01/2024

This policy applies to Non-Participating outpatient hospitals, ambulatory surgical centers (ASCs), birth centers, outpatient behavioral health treatment facilities, independent laboratories, physicians and other qualified health care professionals.

Note: Certain NonPar payment methodologies are not applicable to Medicare Advantage claims.

Definitions

Non-Participating (NonPar) Provider
A provider who has not entered into a contractual agreement with our health plan for the member's product. Also referred to as Out-of-Network Provider.

(See Policy Cross References for additional definitions)

Policy statement

Claims submitted by NonPar providers will be processed according to the NonPar payment methodology in place at the time of service. Claims may be subject to, but are not limited to, the following:

  • Bundled services may include the application of, but are not limited to, the following:
    • National Correct Coding Initiative (NCCI)
    • Correct Code Editor (CCE) Code Pairs (Not applicable to Medicare Advantage)
    • ClaimsXten™ Unbundled Code Pairs (Not applicable to Medicare Advantage)
    • Incidental Unlisted Codes
  • Clinical Edits may include, but are not limited to the following:
    • Non-Reimbursable Services
    • Unlisted Code Review
    • Investigational Denials (Not applicable to Medicare Advantage)
    • Not Medically Necessary Denials
    • Cosmetic Denials (Not applicable to Medicare Advantage)
    • Benefit Denials
  • National Physician Fee Schedule Relative Value File (NPFSRVF) pricing rules including, but are not limited to, the following:
    • Procedure Code Status Indicators
    • Global Periods
    • Modifier Pricing, including:
      • Professional/Technical Component
      • Multiple Service Reduction (MSR)
      • Multiple Procedure Pricing Reduction (MPPR) (Applicable to Medicare Advantage)
      • Bilateral Pricing
      • Assistant Surgeon Pricing
      • Co-Surgeon, Team Surgeon Pricing
  • ClaimsXtenTM Rules
  • Medically Unlikely Edits (MUEs)
  • Integrated Outpatient Code Editor (I/OCE) Clinical edits
  • Inclusive Facility Fee Services (i.e., ASCs)
  • Correct Coding Validation Audits
  • Medical Policies, Reimbursement Policies and Administrative Manual
  • Reimbursement at the lesser of billed charges or the NonPar reimbursement methodology allowed amount.
  • Freestanding ASC payment methodology is based on Centers for Medicare & Medicaid Services (CMS) ASC payment system, as well as CMS Outpatient Prospective Payment System (OPPS) with our health plans modifications.
  • Outpatient Hospital payment methodology is based on CMS Outpatient Prospective Payment System (OPPS)
  • The Federal No Surprises Act (NSA). Reimbursement will be paid at the Qualified Payment Amount (QPA). (Not applicable to Medicare Advantage)

  • The Washington Balance Billing Protection Act (BBPA). Reimbursement will be paid at the Commercially Reasonable Rate (CRR). (Not applicable to Medicare Advantage)

References

Centers for Medicare & Medicaid Services (CMS), OCE Purpose

Centers for Medicare & Medicaid Services (CMS), Pub 100-04 Medicare Claims Processing

Current Procedural Terminology (CPT®), American Medical Association

National Ambulatory Surgical Center Fee Schedule, Centers for Medicare & Medicaid Services (CMS)

National Physician Fee Schedule Relative Value File, Centers for Medicare & Medicaid Services (CMS)

NCCI Policy Manual for Medicare Services, current version, Chapter 1, General Correct Coding Policies

WA Balance Billing Protection Act (RCW 48.49.160)

Federal No Surprises Act (86 Fed. Reg. 36872, 36881

Disclaimer

Your use of this Reimbursement Policy constitutes your agreement to be bound by and comply with the terms and conditions of the Reimbursement Policy Disclaimer.