CurrentSelectHealthPolicy 63

Hierarchy of Sources

Defines the hierarchy of authoritative sources SelectHealth uses to create coding and reimbursement policies and states which external guidelines (CMS, CPT, specialty societies, Medicaid) are followed for different product lines. Affects SelectHealth policy authors, auditors, and providers submitting claims.

Policy Summary

PayerSelectHealth

PolicyHierarchy of Sources

Policy CodePolicy 63

Change TypeNo material changes

Effective DateJan 1, 2023

Next Review Date

Key ActionRefer to the member's benefit plan to determine coverage and eligibility; this document informs coding/reimbursement policy but does not determine benefits.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

4-levelordered source tiers (CMS/NCCI, CPT, Specialty Societies, Other Expert Sources)

Commercial & CHIPplans explicitly referenced

Advantage=CMSMedicare alignment

CommunityCare=UtahMedicaid alignment

Coverage Determination Principles

Policy Summary

PayerSelectHealth

PolicyHierarchy of Sources

Policy CodePolicy 63

Change TypeNo material changes

Effective DateJan 1, 2023

Next Review Date

Key ActionRefer to the member's benefit plan to determine coverage and eligibility; this document informs coding/reimbursement policy but does not determine benefits.

SourceLink

On This Page

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

ALL of the following

Primary reference is the Centers for Medicare and Medicaid Services (CMS) guidance, including National Coverage Determinations (NCDs) and Local Coverage Determinations (LCDs). CMS guidance is the first source reviewed for applicability.
Medicaid guidance (including state Medicaid policies) and the National Correct Coding Initiative (NCCI) are considered, particularly when CMS NCD/LCD is not available or when additional coding clarity is needed.
Current Procedural Terminology (CPT) is used next in the hierarchy. CPT may be consulted for coding direction, but SelectHealth determinations may override CPT when CMS or other authoritative guidance conflicts or when SelectHealth policy provides a different position.
Specialty society guidance (for example, AAOS, ACOG) is reviewed and considered alongside CMS and CPT. If specialty society guidance conflicts with CMS or CPT, SelectHealth evaluates all viewpoints prior to issuing a policy position.
Other expert sources — including payer precedents, coding newsletters, and coding references (for example, Ingenix publications) — may be used to inform decisions when gaps remain after reviewing the above sources.
SelectHealth may develop internal policies that differ from external authorities. In those cases, SelectHealth Policy will be used to audit and adjudicate claims for SelectHealth lines of business, subject to any applicable contractual or regulatory requirements.

Plan-specific guidance

SelectHealth Advantage (Medicare) follows CMS guidelines; where SelectHealth policy differs, SelectHealth Policy will be used to audit and adjudicate claims.
SelectHealth Community Care (Medicaid) follows applicable state Medicaid guidance (for example, Utah Medicaid); where SelectHealth policy differs, SelectHealth Policy will be used to audit and adjudicate claims.
Commercial plans and CHIP follow the above hierarchy; SelectHealth Policy may be applied when it differs from external sources.

Operational notes

Coverage policy content and listed codes are informational and do not guarantee member coverage. Benefits and eligibility are determined by the member’s individual benefit plan in effect at the time services are rendered.
SelectHealth makes no representations and accepts no liability for external information cited. Policies are updated periodically and may be amended without separate notice to providers or members.
Providers should verify benefits and preauthorization requirements with SelectHealth prior to rendering services; members and providers may contact SelectHealth for benefit or policy questions as indicated in member materials and provider relations resources.

Policy content and any reproduced external material are proprietary and protected by copyright; reproduction or transmission without permission is prohibited.

Disclaimer

This document is informational and not a substitute for medical advice, plan preauthorization, certification, or an explanation of benefits. Inclusion or exclusion of codes does not imply coverage or reimbursement. Refer to the member’s contract for coverage determinations.

Definitions and Source Hierarchy

Hierarchy of Sources

Tier 1Medicare CMS/NCCI (National Correct Coding Initiative) — NCCI policy manual and CMS National/Local Coverage Determinations are prioritized first for Commercial and CHIP; Medicaid may be considered when no NCD/LCD is available.

Tier 2Current Procedural Terminology (CPT) — CPT is the next resource in the hierarchy; CPT determinations may be overridden by SelectHealth when CMS/NCCI take precedence or when SelectHealth creates differing policy.

Tier 3Specialty Societies — Guidance from societies (e.g., AAOS, ACOG) is reviewed relative to CMS and CPT; disagreements prompt evaluation of all views before decision.

Tier 4Other Expert Sources — Payers, coding newsletters, and publications (e.g., Ingenix/Coders Desk Reference) used as supplemental information.

Override ruleWhen SelectHealth creates policies that differ from external sources, SelectHealth policy will be used to audit and adjudicate claims.

Product-specific guideline alignment

SelectHealth Advantage (Medicare)Follows CMS guidelines; when SelectHealth policy differs from CMS, SelectHealth policy will be used to audit and adjudicate claims.

SelectHealth Community Care (Medicaid)Follows Utah Medicaid; when SelectHealth policy differs from Utah Medicaid, SelectHealth policy will be used to audit and adjudicate claims.

Commercial and CHIP alignmentFor Commercial and CHIP plans, SelectHealth generally prioritizes CMS/NCCI first, then CPT, then specialty societies, then other expert sources; SelectHealth policy may override external sources when created.

OpenPayer

Hierarchy of Sources

Coverage Determination Principles

Referenced Code Systems

Scope, Applicability, and Provider Guidance

Definitions and Source Hierarchy

CPT	Current Procedural Terminology referenced as a primary coding resource after CMS/NCCI
NCCI	National Correct Coding Initiative edits and CMS guidance prioritized first for Commercial/CHIP