Clinical payment and coding policies are based on criteria developed by specialized professional societies, national guidelines (e.g. Milliman Care Guidelines (MCG)) and the CMS Provider Reimbursement Manual. Additional sources are used and can be provided upon request. The clinical payment and coding guidelines are not intended to provide billing or coding advice but to serve as a reference for facilities and providers.
Certain policies may not be applicable to Members who are participants in an employer’s self-funded employee benefit plan for which BCBSNM acts in an administrative capacity and certain insured products. Refer to the Member's Membership Certificate, Benefit Booklet, Benefit Plan, Summary of Benefits and Coverage, or other coverage document (together “Coverage Documents”) to determine whether coverage is provided or if there are any exclusions or benefit limitations applicable to any of these policies. In the event of a conflict between any policy and the Member’s Coverage Document, the Coverage Document will govern.
In the event of conflict between a clinical payment and coding policy and any Coverage Document, the Coverage Document will govern.
In the event of conflict between a clinical payment and coding policy and any provider contract pursuant to which a provider participates in and/or provides Covered Services to Member(s), the provider contract will govern.
Conformance to clinical payment and coding policy is not a guaranty of payment. All other requirements, including but not limited to eligibility at the time of service, medical necessity, and other terms, conditions, limitations and exclusions set forth in the Member’s Coverage Document, continue to apply.