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National Capital PPO (NCPPO) provides network access and related services to payors of benefits provided to members under the terms of a payor-sponsored health benefit plan (“benefit plan[s]"). 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 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 do not constitute plan authorization, nor is it an explanation or guarantee of benefits.
Medical claim pricing and processing services provided by NCPPO are available to a payor. Not all payors purchase such services for the benefit plans they sponsor. For payors who have purchased such services, however, NCPPO claims processing includes a proprietary software product licensed from a vendor, McKesson CodeReview (c). The claims processing logic is periodically reviewed and updated by referencing various resources, including the National Correct Coding Guide, the subspecialty guidelines of CPT-4, and the recommendations of specialists who may be consulted.
NCPPO developed a guide to medical claim pricing for your reference. This guide appears on the following pages and includes:
- NCPPO Customized Claims Edits
- NCPPO Significant Edits
- NCPPO Modifiers 25 and 59 Recognition
Please contact NCPPO Customer Service at 1.800.624.2356 or your local NCPPO network representative If you have questions regarding specific claims adjudication.
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