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Medical Policy and Clinical UM Guidelines

View our medical policies and clinical UM guidelines

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Medicaid Reimbursement Policies

Standard terms used within the majority of our reimbursement policies. For specific policy-related definitions, please view the individual policy. Provider and/or state contract definitions supersede the definitions listed within the document above.  
Claims Requiring Additional Documentation
Claims Submission - Required Information for Facilities
Claims Submission - Required Information for Professional Providers
Claims Timely Filing
Code and Clinical Editing Guidelines
Corrected Claims
Documentation Standards for Episodes of Care
Duplicate or Subsequent Services on Same Date of Service
Emergency Services: Nonparticipating Providers and Facilities
Locum Tenens Physicians
Medical Recalls
Other Provider Preventable Conditions
Present on Admission Indicator for Health Care-Acquired Conditions
Requirements for Documentation of Proof of Timely Filing
Reimbursement for Eligible Billed Charges
Reimbursement for Maximum Units Per Day
Reimbursements for Items under Warranty
Reimbursements of Claims with Charge Discrepancies
Reimbursement of Sanctioned Providers
Scope of Practice
Site of Service Payment Differential – Professionals
Professional Anesthesia Services
Assistant at Surgery (Modifiers 80/81/82/AS)
Diagnoses Used in DRG Computation
Distinct Procedural Services (Modifiers 59, XE, XP, XS, XU)
DME Modifiers for New, Rented and Used Equipment
Modifier 22: Increased Procedural Services
Modifier 24: Unrelated Evaluation and Management Services by the Same Physician
Modifier 25: Significant, Separately Identifiable Evaluation and Management Service
Modifier 26 and TC: Professional and Technical Component
Modifier 57: Decision for Surgery
Modifier 62: Co-Surgeons
Modifier 63: Procedures Performed on Infants less 4kg
Modifier 66: Surgical Teams
Modifier 76: Repeat Procedure by the Same Physician
Modifier 77: Repeat Procedure by another Physician
Modifier 78: Unplanned Return to the Operating/Procedure Room by the Same Physician Following Initial Procedure for a Related Procedure during the Postoperative Period
Modifier 91: Repeat Clinical Diagnostic Laboratory Test
Modifier LT and RT: Left Side/Right Side Procedures
Modifier Usage
Multiple Bilateral Surgery: Professional and Facility Reimbursement
Reimbursement for Reduced and Discontinued Services
Reimbursement of Services with Obsolete Codes
Split-Care Surgical Modifiers
Unlisted or Misc. Codes
DME and Supplies 
Durable Medical Equipment (Rent to Purchase)
Facility Take-Home DME and Medical Supplies
Drug and Injectable Limits
Facility Take-Home Drugs
Evaluation and Management 
Preventive Medicine and Sick Visits on the Same Day
DRG Inpatient Facility Transfers
Preadmission Services for Inpatient Stays
Inpatient Readmissions
Early and Periodic Screening, Diagnostic Treatment
Vaccines for Children Program
Prosthetics & Orthotic 
Prosthetic and Orthotic Devices
Portable/Mobile/Handheld Radiology Services
Multiple Radiology Payment Reduction
Multiple Delivery Services
Abortion (Termination of Pregnancy)
Global Surgical Package
Maternity Services
Robotic Assisted Surgery
Transportation Services: Ambulance and Nonemergent Transport
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