Provider Policies Library | Helpful Resources

Please note that the current policy list is not exhaustive, but rather a collection of policies that providers have expressed an interest in viewing. Amendments, modifications, supplements to these posted policies and/or additional policies may be posted in the near future. If you have any questions regarding these policies, please contact your Provider Relations Representative.


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Clinical Policies


Clinical Documents (A-Z)
Payment Policy: Balloon Sinus Ostial Dilation

Reference Number: CP.MP.119


Clinical Policy: Caudal Epidural Steroid Injections

Reference Number: CP.MP.164


Clinical Policy: Cosmetic and Reconstructive Surgery

Reference Number: CP.MP.31


Clinical Policy: Dental Anesthesia and Facility Services

Reference Number: CP.FC.02


Clinical Policy: Facet Joint Interventions

Reference Number: CP.FC.18


Clinical Policy: Intradiscal Steroid Injections

Reference Number: CP.MP.167


Clinical Policy: Mechanical Stretching Devices

Reference Number: CP.MP.144


Clinical Policy: Medical Necessity Criteria

Reference Number: CP.FC.05


Clinical Policy: Multiple Sleep Latency Testing

Reference Number: CP.MP.24


Clinical Policy: Nerve Blocks for Pain Management

Reference Number: CP.MP.170


Clinical Policy: Out-of-Network

Reference Number: CP.FC.20


Clinical Policy: Outpatient Testing for DOA

Reference Number: CP.FC.17


Clinical Policy: Panniculectomy

Reference Number: CP.MP.109


Clinical Policy: Pediatric Tonsillectomy Inpatient

Reference Number: CP.FC.25


Clinical Policy: Polysomnography (PSG)

Reference Number: CP.FC.22


Clinical Policy: Repeat Bariatric Surgery

Reference Number: CP.FC.24


Clinical Policy: Sacroiliac Joint Interventions

Reference Number: CP.MP.166


Clinical Policy: Sclerotherapy for Varicose Veins

Reference Number: CP.MP.146


Clinical Policy: Short Inpatient Hospital Stay

Reference Number: CP.MP.182


Clinical Policy: Thymus Transplant

Reference Number: CP.MP.189


Clinical Policy: Transfer Policy

Reference Number: CP.FC.03


Clinical Policy: Transforaminal Epidural Injections

Reference Number: CP.MP.165


Clinical Policy: Trigger Point Injections

Reference Number: CP.MP.169


Clinical Policy: Video EEG Monitoring

Reference Number: CP.MP.177



Payment Policies


Payment Documents (A-Z)
Payment Policy: 14 Day Readmission (Medicaid)

Reference Number: FC.PP.003


Payment Policy: 30 Day Readmission (Medicare)

Reference Number: FC.PP.004


Payment Policy: Claim Validation of Modifier 25

Reference Number: FC.PP.001


Payment Policy: Claim Validation of Modifier 59

Reference Number: FC.PP.002