General coverage and applicability
Physician services include routine physical examinations and periodic check-ups, sick visits, specialty care office visits, observation care, inpatient care, and home visits. All services must be medically necessary to qualify for reimbursement. Neighborhood may use NCDs, LCDs, InterQual, EOHHS recommendations, and Neighborhood Clinical Medical Policies when determining medical necessity. Providers must verify eligibility, coverage and authorization prior to rendering services.
All services must be medically necessary to qualify for reimbursement. It is the provider's responsibility to verify member eligibility, benefits, and any prior authorization requirements before providing services. For questions contact Provider Services at 1-800-963-1001.
Bundling and inclusive services
Routine venipuncture and other services that are considered inclusive with evaluation and management (E&M) or other primary services are not separately reimbursable when billed together.
Routine venipuncture (blood draw) is not separately reimbursable when billed with an E&M service code.
Observation care related to a surgical procedure is included in the global surgical fee and is not separately reimbursable.
Post-surgical visits billed by the physician who performed the surgery are included in the global surgical package and are not separately reimbursable unless the visit is unrelated to the surgery (see post-surgical exception under Inpatient/Observation/Post-op group).
Chronic Care Management (INTEGRITY only)
Chronic Care Management (CCM) services are covered and reimbursable for INTEGRITY only, per CMS guidelines.
CCM applies to patients with two or more chronic conditions expected to last at least 12 months or until death and that place the patient at significant risk of death, acute exacerbation/decompensation, or functional decline.
Eligible practitioners (physicians, physician assistants, clinical nurse specialists, nurse practitioners, and certified nurse midwives) may bill for at least 20 minutes or more of care coordination services per month.
Only one practitioner may bill CCM services per patient during any given month.
CCM is excluded for Medicaid and Commercial members (see Exclusions).
Observation, inpatient, and post-surgical billing rules
Observation, inpatient, and post-surgical billing and documentation rules.
Inpatient admissions: services provided on the same date of service by the same provider in addition to the inpatient stay are considered part of initial inpatient care and are not separately reimbursable.
If a patient is admitted and discharged from inpatient status on the same date, codes 99234-99236 (Observation or Inpatient Care Services including Admission and Discharge) apply.
Prolonged services (99354-99359) may be reimbursed when billed in addition to a base E&M code, are time-based (do not need to be continuous), are not reportable for <30 minutes, and only one prolonged code may be billed per day by the same physician or qualified health professional. Documentation must indicate time spent; notes may be requested.
Observation services: only the physician who admits the patient to observation may report the initial observation E&M code; other physicians should bill appropriate outpatient/office codes for services while the patient is on observation.
Miscellaneous covered services
Miscellaneous physician services covered per CPT when billed appropriately.
Glucose monitoring physician services are covered and reimbursable according to CPT guidelines.
Osteopathic Manipulative Treatment (OMT) is covered and reimbursable according to CPT guidelines.
Newborn services (hospital or birthing center care for newborns including H&P, ordering diagnostics, documentation) are covered per CPT guidelines.
Podiatric nail trimming/debridement coverage
Podiatric trimming/debridement of nails coverage varies by line of business.
Medicaid and INTEGRITY: Covered and reimbursable with no diagnosis restrictions.
Commercial: Covered and reimbursable only for diabetic diagnosis codes in the ranges E08.00-E09.9 and E10.10-E13.9.
Primary care and preventive services criteria
Primary care, preventive, and PCP-specific service rules and limits.
Pediatric preventive office visits: covered per EPSDT schedule; vision and hearing screening are part of the preventive visit and not separately reimbursable.
Pediatric fluoride varnish: covered for members age 6 months to 18.99 years. Limits: Medicaid — 4 units per rolling year; Commercial — 4 units per plan year.
Pediatric autism screening and developmental screening: age- and plan-specific limits apply; prior authorization required for services beyond limits (see Limits section).
Adult routine office visits: covered once per year — Medicaid: one per rolling year; INTEGRITY: one per calendar year; Commercial: one per calendar/plan year.
After-hours care: reimbursable when billed with a sick visit outside normal office hours, on Sundays, or specified holidays. After-hours services are not separately reimbursable in certain excluded circumstances (see Exclusions).
Billing requires pairing specified diagnosis codes with listed CPT/HCPCS codes and modifiers where noted
Billing requires pairing specified diagnosis codes with the appropriate CPT/HCPCS codes and modifiers where noted.
Pediatric Developmental Screening must be billed with diagnosis Z00.121 or Z00.129 and a code from Table 3.
Pediatric Autism Screening must be billed with diagnosis Z00.121 or Z00.129, a code from Table 3, and modifier U1.
Pediatric Fluoride Varnish must be billed with diagnosis Z29.3 and the appropriate code from Table 4.
Prenatal pediatrician office visit must be billed with diagnosis Z76.81 and the appropriate code from Table 5.
Newborn services must be billed with diagnosis codes Z38.00–Z38.8 and the appropriate codes from Table 6 (examples: 99460, 99461, 99462, 99463, 99464, 99465; includes 99184 where applicable).
Coverage stance for listed codes and service expectations
Coverage stance for listed codes and expectations for provider documentation and coding.
Reimbursement follows CPT guidelines and Neighborhood payment policies; providers must ensure accurate E&M level selection, time documentation where required (eg, prolonged services), and adherence to global period rules.
Only one E&M code per practice, per specialty type, per date of service will be reimbursed.
Certain services are excluded (see Exclusions) — examples include CPT 36416 (capillary blood specimen collection), chronic care management for Medicaid and Commercial members, consultation services (99241-99245, 99251-99255, G0425-G0427), and others listed in the Exclusions section.
When billing prolonged services, documentation must clearly indicate total time (face-to-face and non-face-to-face) and support medical necessity; services <30 minutes are not billable.
General claims adjudication and reimbursement considerations
General claims adjudication and reimbursement considerations.
Claims are subject to member eligibility, plan benefits, claims edits, coding and documentation guidelines, authorization policies, provider contract terms, and federal/state regulations.
Neighborhood may require notes or supporting documentation for additional reimbursement (eg, prolonged services, services billed outside global periods, or visits billed with modifier 24).
Policy is informational and not a guarantee of payment; Neighborhood reserves the right to update the policy and all services billed are subject to audit.