2025 Recommended Clinical Review; Post-Service Review and Non-Covered Procedure Code List (Plastic/Reconstructive Surgery)
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Lists procedure codes in plastic/reconstructive surgery and related services that are subject to medical policy review, recommended clinical review, prior authorization, non-coverage, or classified as experimental for Blue Cross Blue Shield - Texas members.
Coverage Criteria and Classifications
Coverage review categories
Coverage stance varies; many procedures are reviewed against Medical Policy Criteria
Submit for Recommended Clinical Review where indicated (see code listings).
Providers should include operative reports and clinical rationale for unlisted codes when requesting review or prior authorization.
Check the Clinical Payment and Coding Policy (CPCP) referenced for ElU details.
Non Covered
Coverage designations shown in this section include:
Review categories (MP Criteria, EIU)
Review and reimbursement policies shown:
Examples span multiple specialties and are listed with the code group entries.
Unlisted Procedures
Unlisted procedures:
Providers should obtain prior authorization where contractually required to avoid denials and should submit detailed documentation describing the unlisted service.
MP Criteria - Reviewed
Applies to many diagnostic and therapeutic CPT codes listed (see code groups).
Non Covered
Examples include acupuncture (97810-97814) and certain administrative/on-call services (99026/99027, 99071).
Unlisted / Prior Authorization
When submitting, include procedure description, operative report, and clinical rationale to support medical necessity.
Procedures/services listed as Non Covered in this code group are not covered by the Plan and are not subject to pre‑service review. Claims submitted for services designated Non Covered will be denied as not covered under the member's benefit plan.
Examples of services explicitly labeled Non Covered include 21032 (Excision of maxillary torus palatinus) and the endosteal implant entries 21248 and 21249; each is annotated in the document as Non Covered: Procedure/service not covered by the Plan. Not subject to pre‑service review.
Several procedures are annotated as ElU/EIU (Experimental/Investigational/Unproven) and are described in the file as procedure/service not reimbursed by the Plan. The list shows examples such as selected device and implant procedures (see phrenic nerve stimulator and related entries) that carry an ElU/ EIU designation and therefore are not reimbursed.
The document also marks some codes as ElU/Plan or Plan. Not subject to pre‑service review, indicating that while the code is associated with the Plan, reimbursement or pre‑service review requirements may vary and the corresponding Clinical Payment and Coding Policy (CPCP) or ElU policy should be checked for details (examples appear in the EGD and phrenic nerve stimulator groups).
Specific code groups are listed as ElU/EIU and annotated as not reimbursed by the Plan (for example, device-related pelvic/urethral implant codes such as 53451–53454 and other listed urologic device codes). Billing these codes is at risk of non‑payment because they are categorized as not reimbursed.
Reproductive and fertility procedures are called out as Non Covered. Examples explicitly listed as not covered include artificial insemination codes 58321 (intracervical) and 58322 (intra‑uterine), sperm washing 58323, and tubotubal anastomosis 58750; these services are not subject to pre‑service review and claims will be denied as not covered.
The file includes explicit Non Covered examples in other specialties; for instance, ophthalmology entry 65760 (Keratomileusis) and the non‑clinical service 69090 (Ear piercing) are annotated as Non Covered: Procedure/service not covered by the Plan and are not subject to pre‑service review.
Additional entries explicitly listed as Non Covered include a range of laboratory, pathology, and necropsy/autopsy codes (for example, necropsy/autopsy codes such as 88000–88045) and reproductive cryopreservation codes (89258, 89259); these are specified as not covered and not subject to pre‑service review.
A cluster of reproductive medicine codes for cryopreservation, storage, and thawing are explicitly labeled Non Covered. Examples include cryopreservation of reproductive tissue and gametes (89335, 89337), storage codes (89342–89346), and thawing procedures (89352–89356); the document makes clear these services are not covered by the Plan.
High altitude simulation tests are identified as Non Covered. Specifically, 94452 and 94453 are annotated as not covered and not subject to pre‑service review.
Certain psychiatric services are designated Non Covered. The document lists examples such as 90885 (psychiatric evaluation of records and accumulated data) and 90889 (preparation of a psychiatric status report) as not covered by the Plan.
Other services explicitly labeled Non Covered include acupuncture codes (97810–97814) and various administrative, on‑call, and non‑clinical services (for example 99026, 99027, 99071); these entries are specified as not covered and not subject to pre‑service review.
Codes labeled EIU are defined in the file as procedure/service not reimbursed by the Plan. The document clarifies that EIU designation indicates the service is experimental, investigational, or unproven and therefore will not be reimbursed.
The EIU designation carries clear coverage implications: services annotated EIU: Procedure/service not reimbursed by the Plan are excluded from reimbursement. The file repeatedly notes that EIU entries are not subject to pre‑service review and will not be paid if billed.
Multiple codes across the list are marked as not reimbursed (EIU/ElU) and the document highlights the risk of denial if those codes are billed. The guidance consistently directs checking the corresponding ElU/CPCP policy when a code is annotated as ElU/ EIU or when the listing indicates Plan‑level exceptions.
In summary, codes with the ElU/EIU label are explicitly stated as not reimbursed by the Plan. Billing these codes without alternate coverage authority will likely result in denial for non‑reimbursement.
The file clarifies that an EIU designation indicates the procedure is considered experimental, investigational, or unproven and therefore is not supported by medical policy in all situations; codes assigned EIU/ElU are described as not reimbursed by the Plan and should be treated accordingly when preparing claims and prior authorization requests.
Cryopreservation and storage services for reproductive materials are specifically listed as Non Covered. The document lists cryopreservation and storage codes (for embryos, sperm, oocytes, and reproductive tissue) as not covered and not subject to pre‑service review.
Additional Non Covered examples and commentary include acupuncture (97810–97814) and multiple administrative or on‑call related codes (99026–99027, 99070–99071), which the file identifies as not covered and not subject to pre‑service review.
The document annotates numerous Category III and temporary CPT/T‑codes with EIU/ElU or MP Criteria labels. Several T‑code examples are shown as EIU/ElU (not reimbursed) or as MP Criteria (requiring Recommended Clinical Review); the listing indicates these T‑codes are not always subject to pre‑service review and providers should follow the CPCP/ElU guidance for each code.
Overall, services annotated ElU or EIU in this file are described as not reimbursed by the Plan. Treat codes with those annotations as excluded from reimbursement unless specific policy language or contract provisions indicate otherwise.
CPT/HCPCS Code Listings and Status
Prior Authorization, Recommended Clinical Review, and Documentation
Prior authorization may be required — general notice
Highlighted procedures and services in this code group may require prior authorization per contract; the unlisted procedure code 15999 is specifically noted as “Unlisted: ... Prior Authorization.” Obtain prior authorization where contractually required to avoid denial.
- Example: 15999 explicitly annotated 'Prior Authorization.'
Prior authorization may be required for unlisted and unspecified codes
Certain CPT entries are labeled 'Unlisted' and may require prior authorization or contract-specific prior authorization; submit pre-service authorization when required by the member’s contract.
- Example unlisted entries include 17999 and other 'Unlisted' designations.
Prior authorization may be required — unlisted and MP Criteria codes require submission per contract
Unlisted CPT codes and codes flagged as MP Criteria should be submitted per contract; unlisted entries may be subject to contract/clinical review and prior authorization may be required.
- Providers should obtain prior authorization per contract agreement for unlisted procedures to avoid post-service denial.
Prior Authorization for Unlisted/Unclassified Procedures
Per the code group descriptions, providers should obtain prior authorization per contract agreement when billing unlisted or unclassified procedure codes; failure to obtain required prior authorization may result in denial.
Recommended Clinical Review for MP Criteria codes
Codes annotated 'MP Criteria' are reviewed against Medical Policy Criteria and the document instructs submission for Recommended Clinical Review (predetermination) to avoid post-service review.
- Submit pre-service Recommended Clinical Review for MP Criteria codes to reduce risk of post-service denial.
Prior authorization may be required — unlisted or otherwise unspecified CPT codes
CPTs listed as 'Unlisted' or otherwise unspecified may require prior authorization per contract agreement; obtain pre-service authorization when required by the contract to avoid post-service review.
Prior authorization recommended for MP Criteria and unlisted codes — submit pre-service when possible
Recommended clinical review or prior authorization is indicated for CPT codes labeled 'MP Criteria' or marked unlisted; providers are advised to submit pre-service when possible to avoid post-service review.
- When codes are annotated MP Criteria or Unlisted, submit Recommended Clinical Review/predetermination before service.
Prior authorization may be required for unlisted procedures — submit per contract
Providers should obtain prior authorization per contract guidance for unlisted procedures; unlisted codes are described as possibly subject to contract/clinical review and prior authorization.
- Check member contract for whether prior authorization is required for specific unlisted CPTs.
Prior authorization may be required for unlisted procedures per contract agreement; check contract for specifics
Unlisted procedure codes are noted as potentially subject to contract/clinical review and may require prior authorization; check the contract for specific requirements before performing the service.
- Example: 21089 (unlisted maxillofacial prosthetic) explicitly notes prior authorization may be required.
Prior authorization may be required for many unlisted or unspecified procedure codes — some explicitly marked Prior Authorization
Many unlisted or unspecified procedure codes in the list are annotated as 'Unlisted' and some entries explicitly indicate 'Prior Authorization'; obtain prior authorization per contract to avoid denial.
- Examples include multiple broad unlisted CPT entries that reference prior authorization.
Prior Authorization may be required for unlisted or otherwise not specifically classified procedure codes
Unlisted or otherwise not specifically classified procedure codes are described as potentially subject to contract/clinical review and may require prior authorization per contract agreement.
- Providers should request prior authorization when the code group indicates 'Unlisted' to avoid post-service review.
90378 requires clinical review — review against Medical Policy Criteria
90378 (RSV monoclonal antibody) is listed as 'MP Criteria' and should be submitted for Recommended Clinical Review against Medical Policy Criteria to avoid post-service review.
- 90378: 'MP Criteria: ... Submit for Recommended Clinical Review to avoid post-service review.'
Prior authorization may be required — unlisted or code-group indicated services may need prior auth
Services coded as Unlisted or in code-groups that reference unlisted designations may require prior authorization per contract; providers should confirm contract requirements before service.
Recommended Clinical Review / Prior Authorization — submit MP Criteria codes pre-service
Codes labeled 'MP Criteria' should be submitted for Recommended Clinical Review pre-service to avoid potential post-service review or denial; predetermination is advised when possible.
- Submit documentation and request Recommended Clinical Review prior to the procedure for MP Criteria codes.
Recommended Clinical Review — pre-service review advised for MP Criteria to avoid post-service denial
Pre-service Recommended Clinical Review is advised for codes annotated 'MP Criteria' to avoid post-service review; submit documentation supporting medical necessity with the review.
- Failure to submit Recommended Clinical Review for MP Criteria codes may lead to post-service review or denial.
Recommended Clinical Review required — codes with MP Criteria should be submitted pre-service
Codes listed with 'MP Criteria' are to be submitted for Recommended Clinical Review to avoid post-service review; treat MP Criteria entries as requiring pre-service clinical review where applicable.
- Examples: T-code groups 0572T–0579T annotated MP Criteria require pre-service submission.
MP Criteria — Recommended Clinical Review required to avoid post-service review for marked codes
Procedures annotated 'MP Criteria' require submission for Recommended Clinical Review; submitting supporting clinical documentation pre-service reduces risk of post-service review.
- Codes marked MP Criteria (e.g., 0659T) indicate Recommended Clinical Review is required to avoid post-service review.
ElU/Plan-coded procedures — check CPCP for reimburseability and pre-service review status
Some procedures are designated 'ElU/Plan' and are described as either not reimbursed by the Plan (ElU) or not subject to pre-service review (Plan); providers should check the associated CPCP/ElU policy for reimbursement status.
Documentation for clinical review — submit supporting medical policy criteria and clinical documentation
When requesting Recommended Clinical Review or prior authorization, submit supporting medical policy criteria and sufficient clinical documentation to demonstrate medical necessity and avoid post-service review.
- Include clinical rationale, relevant operative reports, imaging, and other documentation with the submission.
Submit for Recommended Clinical Review — MP Criteria codes require pre-service submission
Providers should submit recommended clinical review (predetermination) documentation for CPT codes labeled 'MP Criteria' prior to service to avoid post-service review and potential denial.
- Submit clinical history and justification with the Recommended Clinical Review request for MP Criteria codes.
Check CPCP for ElU/EIU procedures — confirm reimbursement and documentation requirements
When code groups reference ElU/EIU or 'Plan: Not subject to pre-service review' check the Clinical Payment and Coding Policy (CPCP) ElU guidance to confirm reimbursement status and any documentation requirements.
Submit for Recommended Clinical Review — guidance for MP Criteria codes to avoid post-service review
Submit pre-service Recommended Clinical Review for codes annotated 'MP Criteria' to avoid post-service review; provide documentation sufficient to support medical necessity with the submission.
- Recommended Clinical Review submissions should include clinical notes, imaging, and procedure rationale.
Clinical documentation for review — include operative report and rationale for MP Criteria or Unlisted codes
Include sufficient clinical documentation when submitting MP Criteria or Unlisted codes for review — for unlisted codes include the operative report and clinical rationale to support medical necessity.
- Unlisted code submissions should describe the specific procedure performed and attach operative/intraoperative reports.
Documentation for MP Criteria — submit clinical documentation to avoid post-service review
For codes designated 'MP Criteria' submit clinical documentation that supports medical necessity with the Recommended Clinical Review request to avoid post-service denial.
- Provide records demonstrating how the requested service meets Medical Policy Criteria.
Documentation for unlisted procedure codes — include operative report and clinical rationale
Unlisted procedure codes require specification of the procedure/service performed and may need prior authorization and clinical documentation per contract agreement; include operative reports and clinical rationale with submissions.
Submit clinical documentation for MP Criteria codes — provide policy-linked justification
Submit clinical documentation and request Recommended Clinical Review for codes under 'MP Criteria' to avoid post-service review; documentation should support medical necessity and reference applicable Medical Policy Criteria.
- Ensures timely review and reduces likelihood of denials or post-service medical necessity review.
Submit recommended clinical review documentation — support submissions with policy-referenced clinical evidence
When a code is designated 'MP Criteria' or references Plan/ElU guidance, submit supporting clinical documentation per the referenced Medical Policy Criteria or CPCP to substantiate medical necessity.
- Follow the referenced Medical Policy Criteria or CPCP instructions when preparing documentation.
Submit MP Criteria codes for clinical review — pre-service submission advised
For MP Criteria codes, submit the Recommended Clinical Review request and accompanying clinical documentation prior to service to avoid post-service review or denial.
- Pre-service submission is repeatedly recommended for MP Criteria entries.
Submit supporting clinical documentation — reference Medical Policy Criteria or CPCP when required
When a code is designated MP Criteria or Unlisted, include supporting clinical documentation and check the referenced Medical Policy Criteria or CPCP; this ensures the reviewer can assess medical necessity and contract coverage.
- Include the applicable Medical Policy name/criteria and all relevant clinical records.
Unlisted code documentation — unlisted codes require detailed specification and may need prior authorization per contract
Unlisted procedure codes are defined as not specifically classified and are repeatedly annotated as potentially subject to contract/clinical review and prior authorization — confirm requirements and submit detailed documentation when requesting authorization.
- Example: 15999 and many other unlisted CPTs are annotated 'Prior Authorization' or 'Prior Authorization may be required.'
Documentation for MP Criteria — submit documentation to support medical necessity for MP Criteria codes
For codes labeled 'MP Criteria' submit clinical documentation with the Recommended Clinical Review to support medical necessity and reduce the risk of post-service denial.
- Documentation should explain how the request meets Medical Policy Criteria.
Submit for Recommended Clinical Review — guidance for MP Criteria codes (supporting documentation advised)
Submit Recommended Clinical Review requests for MP Criteria codes prior to service and include supporting documentation; this is repeatedly advised across the document to prevent post-service review.
- Pre-service Recommended Clinical Review reduces likelihood of post-service denial.
Documentation for device evaluation/programming — include physician analysis and programming report
Device interrogation and programming codes require physician or qualified health care professional analysis, review and report; include documentation of physician analysis and any programming reports when submitting for review.
- Examples: 0575T–0579T include expectations for analysis, review, and report by a physician or qualified professional.
Submit for Recommended Clinical Review — repeat guidance for MP Criteria codes
Repeated guidance: codes annotated 'MP Criteria' should be submitted for Recommended Clinical Review pre-service to avoid post-service review; include clinical documentation supporting medical necessity.
- This instruction is reiterated for multiple code groups to emphasize pre-service submission.
Denial triggers from code classification — Non-Covered, EIU, or not on prior auth list may be denied
Procedures classified as Non-Covered, Experimental/Investigational/Unproven (EIU), or not on the prior authorization list may be denied per member benefit plan and Medical Policy; verify member benefits and obtain required authorizations.
- Non-Covered and EIU entries are explicitly noted as not reimbursed or at risk of denial.
Unlisted code prior authorization risk — example 15999
Unlisted procedure codes such as 15999 are flagged 'Unlisted: Procedure/service not specifically defined' and noted as Prior Authorization — failure to obtain required prior authorization may trigger denial or post-service review.
- 15999 is explicitly annotated with 'Prior Authorization.'
Maxillofacial unlisted prior auth risk — 21089 may require prior authorization
Unlisted maxillofacial prosthetic procedure 21089 is annotated as unlisted and may be subject to contract/clinical review and prior authorization; lack of required prior authorization may result in denial.
- 21089: 'Unlisted... maybe subject to contract/clinical review. Prior Authorization may be required per contract agreement.'
Unlisted codes may require prior authorization — examples 22899, 22999
Numerous unlisted procedure codes (e.g., 22899, 22999) are noted as potentially subject to contract/clinical review and prior authorization per contract agreement; not obtaining prior authorization may lead to post-service denial.
MP Criteria-reviewed procedures — submit for Recommended Clinical Review
Codes designated 'MP Criteria' (for example 23929, 27702, 29862, 29866–29868, 29914–29916, 29999) are reviewed against Medical Policy Criteria and should be submitted for Recommended Clinical Review to avoid post-service review or denial.
- MP Criteria designation signals need for predetermination to confirm medical necessity.
Unlisted codes may trigger prior auth/contract review — obtain prior auth when required
Unlisted procedure codes are described as possibly subject to contract/clinical review and prior authorization; providers should obtain prior authorization where required to avoid denial or post-service review.
Unlisted codes and prior authorization risk — check and pre-authorize when necessary
Services coded with CPTs labeled 'Unlisted' (many examples across the list) may be subject to contract/clinical review and prior authorization and therefore risk denial if not pre-authorized.
MP Criteria review triggers — submit for predetermination
Procedures annotated 'MP Criteria' are reviewed against Medical Policy Criteria and recommended clinical review or prior authorization submission is indicated to avoid post-service review or denial.
- MP Criteria designation appears repeatedly with instruction to 'Submit for Recommended Clinical Review to avoid post-service review.'
Unlisted codes may require prior authorization — examples across GI/abdomen lists
Unlisted procedure codes such as 43999, 44238, 44799, etc., may be subject to contract/clinical review and prior authorization; lack of prior authorization may trigger post-service review or denial.
- These unlisted entries are annotated with 'Prior Authorization' in their code group descriptions.
Not reimbursed (ElU/EIU) codes — risk of non-payment
Codes labeled ElU/EIU (for example certain urinary and continence device codes) are noted as not reimbursed by the Plan and therefore pose a reimbursement denial risk if billed.
Clinical review recommended to avoid post-service denial — MP Criteria entries
Failure to submit Recommended Clinical Review for procedures listed as 'MP Criteria' may lead to post-service review or denial; submit pre-service to reduce that risk.
- MP Criteria entries repeatedly instruct submission for Recommended Clinical Review to avoid post-service review.
Unlisted codes may require prior authorization — examples 53899, 54699, 55559, 58578, 58999
Unlisted procedure codes such as 53899, 54699, 55559, 58578, and 58999 are annotated as Unlisted and may be subject to contract/clinical review and prior authorization; failure to obtain required prior authorization may result in denial.
Recommended Clinical Review required for many MP Criteria codes — submit pre-service
Many services labeled 'MP Criteria' require submission for Recommended Clinical Review; failure to submit pre-service may trigger post-service review or denial.
- The document repeatedly states 'Submit for Recommended Clinical Review to avoid post-service review' for MP Criteria codes.
Unlisted codes may require prior authorization — confirm per contract
Unlisted procedure codes may be subject to contract or clinical review and prior authorization may be required per contract; lack of prior authorization may lead to denial.
- A list of unlisted nervous system and other unlisted CPTs note 'Prior Authorization may be required'.
Prior authorization risk for unlisted procedures — numerous entries flagged
Services coded with unlisted procedure codes are frequently annotated to indicate prior authorization risk; providers should obtain prior authorization per contract to reduce denial risk.
- Many unlisted diagnostic and procedure codes (e.g., 76496–76499 group) list Prior Authorization in their group descriptions.
Unlisted codes may trigger review/denial — include detailed documentation
Unlisted procedure codes across many sections (e.g., pathology, reproductive services) may trigger contract review or denial if prior authorization is not obtained; include detailed documentation when submitting.
MP Criteria — submit for clinical review to avoid post-service denial
Codes labeled 'MP Criteria' require submission for Recommended Clinical Review to avoid post-service review; lack of appropriate clinical review/submission may lead to denial.
- Examples: 90378 and various neurostimulation and MEP/MEG codes annotated MP Criteria require pre-service submission.
Prior Authorization risk for Unlisted codes — obtain prior auth as required
Unlisted procedure codes and services may be subject to contract/clinical review and prior authorization; submitting without required prior authorization may trigger post-service review or denial.
- Examples include numerous unlisted administrative, diagnostic, and procedure CPTs annotated as Prior Authorization may be required.
Non Covered services — will be denied if billed
Codes explicitly labeled 'Non Covered' are not covered by the Plan and claims for these services are subject to denial; these services are not subject to pre-service review.
- Examples: acupuncture codes 97810–97814 and various administrative services annotated Non Covered.
Non-reimbursed (EIU) codes — risk of non-payment
Services designated 'EIU' (Experimental/Investigational/Unreimbursed) or with 'ElU: Procedure/service not reimbursed by the Plan' are subject to non-reimbursement and will not be paid.
- Examples: selected T-codes and device procedures annotated EIU/ElU are not reimbursed by the Plan.
MP Criteria — clinical review recommended to avoid denial
Services listed as 'MP Criteria' are reviewed against Medical Policy Criteria and should be submitted for Recommended Clinical Review to avoid post-service review and potential denial.
- Repeated instruction across the document: submit MP Criteria codes for recommended clinical review pre-service.
Recommended Clinical Review advised — failure to submit may lead to post-service denial
Failure to submit for Recommended Clinical Review may lead to post-service review or denial for codes annotated 'MP Criteria'; providers should submit pre-service when possible.
- The document warns that not submitting recommended clinical review may result in post-service review.
EIU / Not reimbursed — check ElU designations before billing
Services annotated 'EIU' or described as 'Procedure/service not reimbursed by the Plan' carry a risk of non-payment if billed; check ElU designations before rendering or billing services.
- Examples: 0424T–0436T group includes several ElU-designated neurostimulator entries.
MP Criteria — submit for recommended clinical review (substernal ICD example)
Procedures with 'MP Criteria' are reviewed against Medical Policy Criteria and should be submitted for Recommended Clinical Review pre-service to avoid post-service review and potential denial.
- Substernal ICD system codes 0572T–0579T are annotated MP Criteria and require Recommended Clinical Review.
EIU/ElU — not reimbursed — verify before performing service
Procedures flagged EIU/ElU are described as 'not reimbursed by the Plan' and therefore carry risk of denial if billed; verify coverage before performing the service.
- Examples include imaging/monitoring codes (0599T) and several T-codes annotated ElU/Plan.
Not reimbursed codes — denial risk for ElU-designated entries
Services coded with codes labeled 'ElU: Procedure/service not reimbursed by the Plan' will not be reimbursed and thus risk denial if billed; do not expect payment for ElU-designated services unless policy changes.
- Examples include donor hysterectomy and related ElU-designated donor/transplant codes.
MP Criteria — potential denial without meeting criteria
Services coded with 'MP Criteria: Procedure/service reviewed against Medical Policy Criteria' require review and may be denied if they do not meet Medical Policy Criteria; submit Recommended Clinical Review with supporting documentation.
- MP Criteria entries carry risk of denial if medical necessity criteria are not met upon review.
Background and Purpose
This file groups procedure codes by how they are reviewed against medical policy criteria — for example, codes that are MP Criteria (reviewed against Medical Policy and recommended for pre‑service clinical review), codes that are Unlisted (not specifically defined and may require prior authorization), and codes designated EIU/ElU or Non Covered (not reimbursed or not a benefit). The purpose of the file is to guide provider submission, predetermination requests, and to identify services at risk for post‑service denial.
Definitions and Key Terms
OpenPayer is powered by Trek Health's payer performance platform. Trek continuously ingests, validates, and normalizes Transparency in Coverage data alongside payer policies and other commercial payer data to create a structured payer intelligence foundation. OpenPayer uses this foundation to deliver personalized search results, dynamically generated policy pages, and tailored policy monitoring based on each user's payers, specialties, billing codes, and areas of interest. The same intelligence powers broader payer performance workflows, including reimbursement benchmarking, contract evaluation, payer negotiations, and financial decision-making.