Billing Guidelines and Payment Policies

This is not an exhaustive list of all billing, coding and payment guidelines and policies. Guidelines and policies are updated regularly and are subject to change as State, Federal, CMS, AMA, Neighborhood and other industry standards change.

To inquire about guidelines not listed here, please contact Provider Services. These guidelines are not intended to certify coverage availability. While services or technology may be determined by Neighborhood to be medically necessary, it may not be part of a member's benefit plan.

For more information please review your Provider Manual or contact Neighborhood Member Services at 1-800-459-6019 for more information about any of our programs.

Find an Administrative Billing / Coding Guideline and Payment Policies from our alphabetical list:

All links below are PDFs.

A

• Adult Day Care Coverage Summary [141KB]
• Ambulatory Surgical Centers Billing and Reimbursement Guidelines [234KB]
• Anesthesia Billing and Reimbursement Policy [431KB]
• Annual GYN Exams CHC Billing Guideline [277KB]
• Assisted Living [398KB]

B

• Biopsy Services Lab and Path Billing Guidelines [212KB]

C

• Cardiovascular and Peripheral Vascular Coverage Summary [167KB]
• Chemotherapy Billing Guidelines [281KB]
• Childrens' Care Coverage Summary [300KB]
• Claims Requirements 1500 Professional Form  [243KB]
• Claims Requirements UB Institutional Form  [237KB]
• Consultation Billing Guidelines [406KB]
• Corrected Claim Submission Policy [62KB]
• Critical Care Billing Guidelines [286KB]
• Cross Over Claims Billing Guidelines [349KB]

D

• Date Range Outpatient Billing Guideline [135KB]
• Diabetes Prevention Program Coverage and Payment Policy  [163KB]
• Dialysis Coverage Summary [292KB]
• Digestive Coverage Summary [239KB]
• Durable Medical Equipment (DME) Coverage Summary [181KB]

E

• Ear Coverage Summary [239KB]
• Electronic Claim Reconsideration Submission Policy [112KB]
• Extended Family Planning (EFP) Coverage Summary [289KB]
• EKG Interpretation and Report with Surgeon Billing Guidelines [212KB]
• Emergency Department Services Evaluation and Management Codes Billing Guidelines [212KB]
• Evaluation and Management Guidelines [294KB]
• Exploratory Surgery Billing Guidelines [211KB]

F

• From and To Dates Date Range Billing Guidelines [211KB]

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G

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H

• Hemic Lymphatic Coverage Summary [166KB]
• Home Health Services [505KB]
• Hospice Coverage Summary [153KB]
• Hospital Inpatient Billing Guidelines [212KB]
• Hospice Billing & Reimbursement Guideline

I

• Immunizations and Vaccines Billing and Reimbursement Policy [526KB] (12-15)
• Immunosuppressive Therapy During a Global Period [273KB]
• Implants Coverage Summary [219KB]
• Inpatient Neonatal and Pediatric Critical Care Coverage Summary [283KB]
• Integumentary and Musculoskeletal Coverage Summary [163KB]

J

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K

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L

• Labor Evaluation Billing Guidelines [211KB]
• Laboratory Coverage Summary [259KB]
• Lesion Excision Surgery Billing Guidelines [280KB]

M

• Male Genital and Urinary System Coverage Summary [162KB]
• Mammography Screening Billing Guidelines [278KB]
• Maternity Coverage Summary [233KB]
• Mediastinum and Diaphragm Coverage Summary [164KB]
• Modifier Billing Guidelines [731KB]
• Multiple Radiological Procesdures Performed in an Outpatient Facility Setting Guidelines [274KB]

N

• Nervous Endocrine System Coverage Summary [224KB]
• Never Events Billing Guidelines [140KB]
• New Versus Established Patient Billing Guidelines [276KB]
• Non-Covered Services [214KB]

O

• Observation Evaluation and Management Billing Guidelines [213KB]
• Obstetrical Billing Guidelines [282KB]
• Opthalmology Billing Guidelines [KB]
• Oral Surgery Coverage Summary [153KB]
• Outpatient Surgery and Procedures Coverage Summary [436KB]

P

• Pain Coverage Summary [149KB]
• Patient Education Coverage Summary [258KB]
• Pediatric Critical Care Transport Billing Guidelines [286KB]
• Pharmaceutical Coverage Summary [325KB]
• Pharmaceuticals NDC Billing Requirements Policy  [667KB] (10-15)
• Pharmaceutical Supplies Billing Guidelines [276KB]
• Physician Coverage Summary [272KB]
• Preventive Medicine Billing Guidelines [277KB]
• Psychological Assessment Coverage Summary [243KB]

Q

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R

• Radiology Service Coverage Summary [246KB]
• Reason Codes [180KB]
• Rehabilitative Therapy Coverage Summary [269KB]
• Respiratory Coverage Summary [150KB]

S

• Skilled Nursing Facility Payment Policy  [137KB]
• Special Services Procedures and Reports Billing Guidelines [282KB]
• Surgical Global Fee Period Billing Guidelines [216KB]

T

• Telemedicine Payment Policy [243KB]
• Therapeutic Services Physical & Occupational [383KB]
• Transplant Coverage Summary [206KB]
• Transportation Coverage Summary [274KB]

U

• UB 04 General Claim Submission [350KB]
• Unlisted Unspecified Procedure Codes Billing Guidelines [277KB]

V

• Venipuncture Billing Guidelines [212KB]
• Venous Procedures with Surgery Billing Guidelines [211KB]
• Vision Care Services Billing Guidelines [431KB]
• Vision Care Services Coverage Summary [293KB]

W

• Womens' Care Coverage Summary [179KB]

X

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Y

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Z

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