CurrentAnthemPolicy CRHPAP - 003

Not Otherwise Classified (NOC) Non-Drug

Defines how Anthem Central Region adjudicates and reimburses covered non-drug services billed using NOC (Not Otherwise Classified) codes for members in applicable programs, including Employer Group Retiree Medicare Advantage; applies to listed states and Central Region providers.

Policy Summary

PayerAnthem

PolicyNot Otherwise Classified (NOC) Non-Drug

Policy CodePolicy CRHPAP - 003

Change TypeNo material change

Effective DateFeb 7, 2019

Next Review Date

Key ActionSubmit the claim with relevant documentation specific to the service (e.g., medical service description, operative report, radiology/pathology reports, supply invoices with make/brand/model and price).

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

Documentation-drivenDocumentation-driven

5 statesState applicability

Robotic/laparoscopicExamples of new technology

Coverage and Reimbursement Criteria

Coverage and reimbursement criteria for NOC non-drug services

Covered when ALL of the following are met:

ALL of the following

ALL of the following
- Medical service: description of service provided for the reported date of service
- Surgery service: copy of operative report
- Radiology service: copy of radiology report
- Pathology/laboratory service: copy of the pathology or lab report

Policy Summary

PayerAnthem

PolicyNot Otherwise Classified (NOC) Non-Drug

Policy CodePolicy CRHPAP - 003

Change TypeNo material change

Effective DateFeb 7, 2019

Next Review Date

SourceLink

On This Page

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Billing, Documentation, and Pricing Actions for Providers

Documentation Required

Documentation submission for NOC claims

For claims submitted as Not Otherwise Classified (NOC) or when an unlisted code is used, providers must submit supporting documentation to allow appropriate code identification and pricing. Documentation should include a clear description of the service provided on the date of service and any operative, radiology, pathology/laboratory, dental, prosthetic/orthotic, hearing/vision reports, or invoices as applicable. Examples of acceptable documentation: medical service description, operative report, radiology report, pathology/lab report, description of supplies with make/brand/model and invoice showing price, dental procedure description, and prosthetic/orthotic device description with invoice and price.

Include a description of the medical service for the reported date of service
Attach operative report for surgical services
Attach radiology report for radiology services
Attach pathology or laboratory report for pathology/lab services
Provide make, brand, model number and invoice with price for medical/surgical supplies
Provide dental procedure description or dental report for dental services
Provide prosthetic/orthotic device description and invoice with price
Provide description of service for hearing/vision services

Billing Rule

Use of specific CPT/HCPCS code when available

When a valid specific CPT or HCPCS code exists for the service provided, providers must report that specific code rather than an unlisted/NOC code. If, after review of submitted documentation, a valid non-NOC CPT or HCPCS code is identified, reimbursement will be based on that code and the associated fee in the provider's applicable Central Region fee schedule.

Report the most specific CPT/HCPCS code available for the service performed
Do not use unlisted/NOC codes when a specific code accurately describes the service
If documentation identifies a specific code post-submission, adjudication and reimbursement will be based on that identified code

Note

Pricing determination factors

Pricing for NOC or unlisted items is determined after review of submitted documentation and may be based on one or more of the following factors. Providers should submit invoices and any manufacturer pricing information when available to support pricing determinations.

Copy of provider's invoice (if requested/submitted)
Manufacturer's list price for the item or similar item(s)
Competitive market rate
Like or comparable code identified during review
Reimbursement based on the applicable Central Region fee schedule when a valid non-NOC code is identified

Definitions

New Technology

DefinitionNew Technology - Reimbursement is based on the current CPT/HCPCS code for the procedure performed, not the methodology or technology used; if a CPT/HCPCS code specifies the technology or methodology in its definition, reimbursement is based on that code.

ExamplesExamples of new technology include robotic surgery (S2900) and laparoscopic surgery.

Pricing implicationReimbursement follows existing CPT/HCPCS coding and associated Central Region fee schedule rather than the particular device or method used.

Documentation relevanceWhen adjudicating claims involving new technology, Anthem reviews claim documentation and may identify a valid non-NOC CPT/HCPCS code to determine reimbursement.

OpenPayer

Not Otherwise Classified (NOC) Non-Drug

Coverage and Reimbursement Criteria

HCPCS / CPT References

Billing, Documentation, and Pricing Actions for Providers

Definitions