![]() This policy describes the payment calculation made when the amount billed on a claim is less than the CMS or Clover allowed amount.Ĭarrier Priced Codes Reimbursement Policy For example Bilateral specific codes or procedure codes on the RBRVS fee schedule with specific bilateral indicators. Outlines requirements of when bilateral pricing is applied to a claim. For examples required modifiers 80, 81,82 and AS.īilateral Procedures Reimbursement Policy Outlines requirements and guidelines used in the payment of assistant surgeon charges submitted on a claim. This policy describes the codes permitted to be billed, as well as frequency limitations for the services provided.Īssistant at Surgery Reimbursement Policy Outlines requirements and guidelines used in the payment of an anesthesia claim.Īnnual Wellness Services Reimbursement PolicyĬlover Health allows members to receive annual preventative wellness visits with no cost share required. This policy describes the requirements and limitations for joint response ambulance claims when billing services for Clover members. ![]() This policy reviews billing requirements for codes considered to be add on codes per CMS. When facilities participate in the 340B program, outpatient claim submissions are required to include specific modifiers to indicate whether or not the drug billed was purchased as part of the 340B program. The Health Resource and Services Administration (HRSA) 340B Drug Pricing Program allows 340B eligible facilities to purchase drugs at a discounted rate through the 340B program. ![]() This policy addresses the process and rules around prepay readmission review If CMS (Centers for Medicare and Medicaid Services) hasn't provided an end date for the disaster or emergency, plans will resume normal operation 30 days after the initial declaration.ģ0 Day Readmission Review and Reimbursement Policy The 30-day notification requirement to members is waived, as long as all the changes (such as reduction or cost-sharing and waiving authorization) benefit the member.Plan-approved out-of-network cost-sharing amounts are temporarily reduced and.Where applicable, requirements for gatekeeper referrals are waived in full.Part A, Part B, and supplemental Part C plan benefits are to be provided at specified non-contracted facilities (note that Part A and Part B benefits must be obtained at Medicare-certified facilities).If you're affected by a disaster or emergency declaration by the President or a Governor, or an announcement of a public health emergency by the Secretary of Health and Human Services, there is certain additional support available to you.
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