Benefit Payment Guidelines & Medical Policies
Please refer to the following menus to access benefit payment guidelines and medical policies treatments and services. To see the full list of options in expanded view, click on the + on each menu.
- Acupuncture
- Abdominal Aortic Aneurysm (AAA) Screening
- Ambulance Services
- Autism Spectrum Disorder
- Behavioral Health Levels of Care
- Breast Pumps and Lactation Services
- Cardiac Monitoring Holter and Event Monitor
- Cardiac Rehabilitation
- Casting and Dressing Application
- Cataract Surgery Intraocular Lenses (IOL)
- Chemotherapy Drug Coverage
- Colorectal Cancer Screening
- Contraceptives and Contraceptive Services
- Dental Anesthesia
- Diabetic Shoes & Inserts
- Emergency Care
- End Stage Renal Disease (ESRD)
- Hearing Aids
- Hospice Care
- Hyperbaric Oxygen (HBO) Therapy
- Infertility
- In-Network and Out-Of-Network Level of Benefits Hospital Services
- Lab – Blood Draws
- Nutritional (Diet) Counseling
- Observation Stay
- Obsolete or Unreliable Diagnostic Tests and Services
- OB Ultrasounds
- Pain Management
- Prenatal Care
- Preventive Services
- Rabies Vaccine
- Telemedicine Policy
- Umbilical Cord Blood Harvesting, Storage and Freezing
- Unlisted and Unspecified Codes