This information is for the sole use of our contracted providers and contains confidential and proprietary information. Any unauthorized review, use, disclosure or distribution is prohibited by the terms of your provider agreement with NCPPO and HealthLink. No part of this publication may be reproduced, stored in a retrieval system, or transmitted, in any form or by any means, electronic, mechanical, photocopying, or otherwise, without permission from NCPPO and HealthLink.
Inclusion of a procedure code or edit in the list below does not imply or guarantee coverage. Furthermore, Reimbursement Policies/Edits evolve over time, and we reserve the right to review and update these Reimbursement Policies/Edits periodically.
NCPPO and HealthLink reprices all claims for contracted payors. All repricing and payor adjudication is in accordance with the Provider Agreements. Payors may be insurance companies or other groups such as self-insured employers, trusts, or governments. Usually, benefits for medical services or supplies that are payable under the terms of a benefit plan are paid directly by the payor. For some payors, NCPPO and HealthLink acting as TPA may make benefit recommendations and payments on behalf of the payor using payor funds.
The administrator of the benefit plan retains authority with respect to eligibility, coverage and the benefits under the benefit plan. Coverage recommendations are subject to all terms and conditions of the applicable benefit plan, including specific exclusions and limitations, and to applicable state and/or federal law. Medical claim guidelines neither constitute plan authorization, nor an explanation or guarantee of benefits.
NCPPO and HealthLink prices claims based on its contracts using a proprietary software product licensed from a vendor, McKesson CodeReview®. The claims processing logic is annually reviewed and updated by McKesson. NCPPO and HealthLink has the ability to customize portions of the CodeReview® software and utilize various resources in making customization determinations. These include the National Correct Coding Initiative (NCCI), Medicare guidelines, and physician specialty societies.
NCPPO and HealthLink developed a medical claim pricing guide for your reference including:
If you have any further questions regarding specific claim adjudication, please contact your Network Consultant or click here to access "Claim Processing Guidelines" within the Administrative Manual.
