Effective January 1, 2015, we are introducing changes
related to the application of medical and claim payment
policies, as well as clinical relationship logic, for IBC?s
Medicare Advantage business.
Policy changes
Medical and claim payment policies that currently apply
to both commercial and Medicare Advantage business
will be separated into two unique policy portfolios:
one for Medicare Advantage business and one for
commercial business.
The new Medicare Advantage policy portfolio will
become effective January 1, 2015; notifications for these
policies will be available on the IBC Medical Policy Portal
by October 1, 2014. This policy portfolio will be based on
Medicare coverage guidance as well as additional IBC
medical and claim payment policy determinations.
Note: The existing policy portfolio will continue to apply
to commercial business.
Clinical relationship logic (procedure
code-to-procedure code edits)
Effective January 1, 2015, the following will be applied
to claims submitted on the CMS-1500 claim form or
through the 837P transaction for Medicare Advantage
HMO and PPO members:
- Medicare's National Correct Coding Initiative (NCCI) editing;
- other clinical relationship logic, which is based on procedure code editing
standards.
For more information
Additional information about these changes will be
provided in future editions of Partners in Health
UpdateSM.
Stay up-to-date on policy activity by visiting the IBC Medical Policy Portal and selecting Accept and Go to Medical
Policy Online. You can also view policy activity using
the NaviNet® web portal by selecting Reference Tools
from the Plan Transactions menu, then Medical Policy.
Be sure to check back often, as the site is updated
frequently.
NaviNet® is a registered trademark of
NaviNet, Inc., an independent company.