Reimbursement policies disclaimers
These policies serve as a guide to assist you in accurate claims submissions and to outline the basis for reimbursement if the service is covered by a Wellpoint member’s benefit plan. The determination that a service, procedure, item, and the like, is covered under a member's benefit plan is not a determination that you will be reimbursed.
Additional reimbursement policy disclaimers
Services must meet authorization and medical necessity guidelines appropriate to the procedure and diagnosis, as well as to the member’s state of residence.
You must follow proper billing and submission guidelines. You are required to use industry standard, compliant codes on all claim submissions. Services should be billed with CPT® codes, HCPCS codes, and/or revenue codes. The codes denote the services and/or procedures performed. The billed code(s) are required to be fully supported in the medical record and/or office notes. Unless otherwise noted within the policy, our policies apply to both participating and non-participating providers and facilities.
If appropriate coding/billing guidelines or current reimbursement policies are not followed, we may:
- Reject or deny the claim.
- Recover and/or recoup claim payment.
These policies may be superseded by mandates in provider or State contracts or State or Federal requirements. We strive to minimize delays in policy implementation. If there is a delay, we reserve the right to recoup and/or recover claims payment to the effective date in accordance with the policy. Wellpoint reserves the right to review and revise its policies periodically when necessary. When there is an update, we will publish the most current policy to the website.
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We look forward to working with you to provide quality service for our members.