Non-Covered CPT/HCPCS Codes - Medicare
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Governs reimbursement and denial of CPT and HCPCS codes deemed non-covered for Healthfirst Medicare Advantage lines of business; applies to providers submitting claims to Healthfirst Medicare Advantage, Medicare HMO and PPO plans.
No material clinical or coverage changes in this revision.
Coverage Stance and Denial Rules
Coverage stance for non-covered and restricted codes
Healthfirst will deny reimbursement for codes designated non-covered by Medicare status indicators, codes marked Not Approved or lacking CMS validation, and certain restricted/ambiguous codes that require formal review.
Medicare Indicators, CMS Fee Schedule, and Code Listings
| N | Non-covered (Medicare status indicator) - non-reimbursable |
| X | Statutory exclusion - non-reimbursable |
| I | Invalid for Medicare - non-reimbursable unless reviewed |
| M | Not valid for Medicare - non-reimbursable unless reviewed |
| R | Restricted coverage - not reimbursed unless formally reviewed |
Billing Rules, Denial Risk, and Appeals
Automatic denial for codes with Medicare non-coverage indicators
Do not submit CPT/HCPCS codes that are assigned Medicare status indicators denoting exclusion or non-payment (for example: 'N', 'X', 'I', 'M'). Such codes are automatically denied regardless of provider type or service location.
- 'N' - Non-covered
- 'X' - Statutory exclusion
- 'I' - Invalid for Medicare
- 'M' - Not valid for Medicare
Do not bill non-covered codes separately; use covered codes or bundling
Do not submit non-covered codes for separate payment. Providers must either bill an appropriate approved covered code or bundle the service within a related covered procedure when appropriate.
- Do not submit non-covered codes for separate payment.
- Use an appropriate, approved covered code when available.
- Bundle the service within a related covered procedure when appropriate.
No reimbursement without formal Healthfirst review for ambiguous/escalated indicators
Codes with ambiguous or escalated Medicare status indicators (for example: 'I', 'M', 'R') will not be reimbursed unless Healthfirst performs a formal review; while under review, no payment will be issued.
- 'I' - Invalid
- 'M' - Not valid for Medicare
- 'R' - Restricted coverage
- No payment pending internal assessment by Healthfirst
Comply with CMS NCCI rules to prevent improper unbundling and mutually exclusive coding
Follow CMS National Correct Coding Initiative (NCCI) rules to avoid improper unbundling, submitting mutually exclusive code combinations, or making redundant submissions.
- Ensure coding follows NCCI guidance to prevent improper unbundling.
- Do not submit mutually exclusive code combinations.
- Avoid redundant submissions that violate NCCI rules.
Denial, rejection, and appeals process — follow Provider Manual Subsection 17.6
Claims that do not adhere to this policy will be denied or rejected; providers are responsible for accurate coding. Appeals, corrected claims, claim reconsideration, and related inquiries follow the Healthfirst Provider Manual Subsection 17.6.
- Non-adherent claims will be denied or rejected.
- Final reimbursement depends on benefits, mandates, medical necessity, and contract terms.
- Refer to Healthfirst Provider Manual Subsection 17.6 for claims inquiries, corrected claims, claim reconsideration, and appeal process.
Medicare Status Indicator Definitions
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