Payer clinical guidelines, medical and coverage policies and claims processing edits are often available online. Many are publicly available, though some may require provider registration for access. Following are links to some payer policies and information. To stay informed about payer administrative and policy updates, review payer newsletters and consider subscribing for email updates from payers.
Many answers to questions can be found in your provider manual or contract. If you are experiencing a payer-related issue, typically the first step is to contact the payer directly to try to resolve the issue. If you disagree with a decision on a claim, make sure to follow the applicable payer process for appeals and disputes. If unable to resolve the issue and for other issues related to payer policies and coverage, please fill out a form (previously known as the Hassle Factor Form) on our Coding Hotline.
Aetna
Cigna
- Reimbursement Policies and Procedures:More information is available to registered providers of the CIGNA Care website.
- Provider Newsletters
Elevance Health (Anthem)
- Policies, Guidelines & Manuals - Select appropriate state
- Provider News
Humana
TRICARE
UHC
- Commercial Medical, Drug & Reimbursement Policies (Including clinical guidelines)
- Community Plan Medical, Drug and Reimbursement Policies (Including clinical guidelines)
- Smart Edits (claims processing tool)
- News Updates for Providers
Last Updated
03/04/2022
Source
American Academy of Pediatrics