ConnectiCare will process Medicare claims according to Medicare payment rules and specialty society guidelines, unless specified otherwise in a provider contract. If a billing or claims payment policy for a particular service is not addressed in this section, follow procedures that are considered standard rules of the Centers for Medicare & Medicaid Services (CMS). This information is available at the CMS website.

ConnectiCare applies the CMS National Correct Coding Initiative (NCCI) edits for claims editing. Certain inpatient evaluation and management procedures are identified in the NCCI manual as not being separately reimbursable, even if a modifier such as modifier 25 is added to the procedure code. NCCI edits apply to claims from all providers in the same specialty and group. There are no exceptions to these edits based on sub-specialty or different diagnoses. Please refer to the CMS NCCI manual regarding reporting of evaluation and management services as needed.

Medicare PPM/11.12