Reimbursement Policies

Reimbursement Policies These Reimbursement Policies for determining reimbursement shall apply to Covered Services rendered to Covered Individuals, except as otherwise may be provided herein. Plan Fee Schedules list the maximum amount payable for each Covered Service that corresponds to a single service code. The preponderance of valid service codes is from Current Procedural Terminology (CPT), Healthcare Common Procedural Coding System (HCPCS), American Dental Association (ADA), or National Drug Codes (NDC). When more than one service (represented by more than one service code) is provided to the same patient on the same day (or sometimes, within the same episode of care), the total fee schedule amount may be less than the sum of fee schedule amounts for individual billed service codes. Aggregations of different service codes may be subject to bundling via Anthem s multiple, incidental, combination, global processing and other reimbursement and edit rules. Anthem reserves the right to apply the most restrictive rule. Although the details of rebundling logic will vary from payer to payer, the concepts of quantity limits as well as multiple, incidental, combination and global processing are industry standards utilized by most payers, including Medicare. Anthem s rebundling logic for Par, PPO, commercial HMO products and Medicare Advantage lines of business is developed internally. HMO Medicaid Reimbursement Policies are available at http://www.anthem.com/. NOTE: The Health Plan will be migrating its claim processing systems as part of an enterprise initiative to consolidate the multiple platforms that are in existence today. This migration is expected to commence January of 2014 and will take approximately 18 24 months to complete. Concurrent with the claim processing system migration, the Health Plan will begin migrating lines of business to utilize the McKesson ClaimsXten claims editing solution. ClaimsXten is utilized in the healthcare financing industry, and is updated by McKesson from time to time. Anthem may adopt the McKesson updates as they occur. Providers will see claims edited using our internally developed editing logic as well as the ClaimsXten edits which may differ. The material differences are noted in this document. See the remainder of this document for key reimbursement policies and edits. Billing Form and Claims Reporting Requirements Provider shall submit all claims on a CMS 1500 claim form or its successor. Provider shall report all Health Services in accordance with the reporting guidelines and instructions contained in the AMA CPT, CPT Assistant, and HCPCS publications. Plan audits that result in identification of Health Services that are not reported in accordance with the AMA CPT, and CPT Assistant publications, will be subject to recovery through remittance adjustment or other recovery action. In addition, updates to Anthem s Claims processing filters and edits, as a result of changes in AMA CPT, and CPT Assistant reporting guidelines and instructions, shall take place automatically and do not require notice, disclosure or amendment to Provider. Limits, Secondary and Subsequent Procedures Multiple units of the same service code may be subject to limits and to fractional payments for secondary and subsequent units of service. For some service codes which may be provided multiple times to a single patient on a single day, Anthem allows a fraction (typically one-half, one-third, or one-fourth) of the usual Plan Fee Schedule amount for secondary and subsequent units of service. For some such service codes, Anthem establishes a maximum total fee schedule amount (limit), notwithstanding the number of units provided. An example of a service limited in this way is obstetric anesthesia. Ultrasonic/Fluoroscopic Guidance Limits CPT codes 76942, 77002, 77003, 77012, and 77021 describe radiologic guidance for needle placement. Anthem allows one unit of service per date of service for any of these codes, regardless of the number of aspirations, biopsies, injections, or localizations performed. Form No.: Plan CompensationScheduleAttachment (03/01/13) page 2

Multiple Surgeries/Procedures (billed with or without modifier 51) Multiple surgery/procedure reimbursement rule (100% primary procedure and 50% for each subsequent procedure) is normally applied to claims for multiple surgeries/procedures performed at the same operative session (however see exception to subsequent percentage reimbursement for multiple endoscopic procedure codes). Codes denied as part of incidental processing are not subject to any reimbursement. When extraordinary circumstances exist, Anthem reserves the discretion to establish a case rate, or whole case allowance. Anthem uses the multiple procedure indicators 2 and 3 as designated in the CMS National Physician Fee Schedule Relative Value File to determine which procedures are eligible for multiple surgery reductions, however CPT Add-on and Exempt from Modifier 51 procedures are exempt from multiple surgery reduction rules. Note Multiple surgery processing of bilateral surgeries may differ under the ClaimsXten claims editing solution. If the bilateral surgery is considered a secondary surgery procedure(as opposed to the primary surgery procedure), ClaimsXten will first apply the bilateral modifier percentage of 150%, then apply the multiple surgery reduction percentage of 50%, for an effective reimbursement percentage of 75% of the fee allowance. Multiple Maternity Reimbursement Methodology Vaginal multiple deliveries: are eligible for separate reimbursement based on the American College of Obstetricians and Gynecologists (ACOG) recommendation. - The appropriate global delivery code isallowed at 100% of the maximum allowance. Global vaginal delivery codes include 59400, 59610 and postpartum inclusive 59410. - The appropriate vaginal delivery only code, with modifier 59 appended, should be billed for each additional birth and will be allowed at 50% of the maximum allowance. Delivery only codesare 59409 and 59612. C-section multiple deliveries (single delivery method): either the global, postpartum inclusive, or delivery only c-section code should be billed and is allowed at 100% of the maximum allowance. Global c-section codes include 59510, and 59618, postpartum inclusive 59515, and 59614. Anthem follows ACOG guidelines and does not allow additional reimbursement for additional births when all babies are delivered by c-section. Delivery only codes include 59514, and 59620. Modifier 22 can be attached to the global or delivery only c-section code if the physician work required for the multiple births is substantially greater than typically required. - Documentation supporting the additional work must be submitted with the claim in order for Modifier 22 to be considered. - Examples of when additional reimbursement may be allowed include but are not limited to : increased intensity, time, technical difficulty of procedure, and severity of patient s condition. Combined c-section and vaginal multiple deliveries: The provider should report the appropriate global vaginal delivery code for the first delivery, and the c-section delivery only code with modifier 59 appended, for any additional c-section deliveries. Additional deliveriesare subject to the standard multiple surgical reimbursement policy. Assistant Surgeon Services 1. Anthem considers the following points to be important considerations in the adjudication of an Assistant Surgeon claim: 2. The provider of service must be a licensed practicing M.D., D.P.M., D.D.S., D.O., PA (Physician Assistant), RNFA (Registered Nurse First Assistant) or CNM (Certified Nurse Midwife) to be eligible for reimbursement as an Assistant Surgeon for a covered procedure. 3. Only one Assistant Surgeon is eligible for reimbursement per covered surgical procedure. 4. CPT codes reported with an Assistant Surgeon modifier are subject to multiple surgery reimbursement rules, if applicable. 5. Procedures reported with an unlisted CPT code will be retrospectively reviewed for pricing and eligibility for reimbursement for an Assistant Surgeon. 6. Some procedures may require assistance for positioning, and retraction for maintaining visualization. However, this type of assistance can usually be performed by a surgical technician and does not require Assistant Surgeon services. Form No.: Plan CompensationScheduleAttachment (03/01/13) page 3

Methodology for Determining Assistant Surgeon Edit Designations Anthem uses the American College of Surgeons (ACS) as its primary source for determining Assistant Surgeon always and never designations. If the ACS designatesa code asan always, Anthem assignsan always: designation to the procedure code, and Assistant Surgeon services will be eligible for reimbursement when reported with that procedure.* - *Exception: Anthem considers CPT codes 59510, 59515, 59618, and 59622 as global delivery codes which are not eligible for Assistant Surgeon reimbursement. If the ACS designatesa code asa never, Anthem assignsa never designation to the procedure codes, and Assistant Surgeon servicesare not eligible for reimbursement when reported with that procedure. When the ACS indicates that an Assistant Surgeon may sometimes be required for a certain procedure, or has not assigned a designation to the code (e.g. newly created CPT codes), Anthem refers to the designations assigned by The Centers for Medicare & Medicaid Services (CMS), along with input from its own Anthem physicians, to assign a designation. If CMS designatesa code asan always, Anthem assigns the always designation to the procedures code. If CMS designatesa code asa never, Anthem assigns the never designation unless Anthem determines that Assistant Surgeon services should be eligible for reimbursement with the code Multiple Endoscopic Procedure Code Reduction Multiple endoscopic surgical reduction (100% primary and a reduced reimbursement % for each subsequent procedure within the base family) is normally applied to claims for multiple endoscopy procedures performed at the same operative session, with the same endoscopic base code as defined by CMS. Codes denied as part of incidental processing would not be subject to any reimbursement. The code ranges are as follows: Codes 29805 29825, 29827-29828 (Shoulder arthroscopy) 100% primary; 30% subsequent Codes 29830 29838 (Elbow arthroscopy) 100% primary; 25% subsequent Codes 29840 29847 (Wrist arthroscopy) 100% primary; 25% subsequent Codes 29860 29863, 29914-29916 (Hip arthroscopy) 100% primary; 25% subsequent Codes 29870 29887 (Knee arthroscopy) 100% primary; 35% subsequent Codes 31622 31625, 31628 31631, 31634-31635, 31636, 31638, 31640, 31641, 31645, 31647, 31648, 31660, 31661 (Bronchoscopy) 100% primary; 25% subsequent Codes 43231, 43232, 43235 43259 (Upper GI endoscopy) 100% primary; 25% subsequent Codes 43260 43272 (ERCP) 100% primary; 25% subsequent Codes 45378 45392 (Colonoscopy) 100% primary; 25% subsequent Multiple Diagnostic Imaging Reimbursement Methodology Anthem will apply a multiple procedure reduction to certain diagnostic imaging procedures when two or more diagnostic imaging procedures are billed together on the same date of service. Anthem uses the multiple procedures indicator of 4 as designated in the CMS National Physician Fee Schedule Relative Value File to determine which procedures are eligible for multiple procedure reduction rules. If two or more procedures with a multiple procedure indicator of 4 are billed together, the procedures are ranked according to RVU to determine primary, secondary, and subsequent procedure. The following reimbursement rules will then apply: Global billed code-100% primary, 65% secondary and subsequent Note: ClaimsXten calculates secondary and subsequent procedures based on the most current RVU values. So ClaimsXten might pay 58% - 65% for the secondary radiology procedure. Form No.: Plan CompensationScheduleAttachment (03/01/13) page 4

Technical component only (modifier TC) 100% primary, 50% secondary and subsequent Professional component only (modifier 26) 100% primary, 100% secondary and subsequent NOTE: Multiple diagnostic imaging procedure reduction may differ under the ClaimsXten claims editing solution when the Global billing is submitted. ClaimsXten logic will result in reimbursement of the primary procedure at 100%. For each subsequent procedure, ClaimsXten logic will calculate an overall Global payment percentage using 100% of the most current CMS RVU for the professional component plus 50% of the most current CMS RVU for the technical component, divided by the most current total CMS RVU. Incidental Processing When multiple codes are billed together, some codes may be considered incidental to other codes and may contribute nothing to the total fee schedule amount for the aggregation of billed codes. A code which is a subset of another code per reasonable interpretation of CPT verbiage will be incidental to the latter code. Code combinations proscribed by the Centers for Medicare and Medicaid Services (CMS) National Correct Coding Initiative will be subject to incidental processing. In addition, Anthem will consider a code incidental to another if the incremental value of the former is less than one-fourth of its usual value when provided in combination with the latter. This will typically be the case when the lesser services do not pertain to different routes of access, different organ systems, different pathological processes, or to multiple trauma. Combination Processing For some aggregations of service codes, Anthem will allow the fee schedule amount for an altogether different service code while disallowing the billed codes. Anthem refers to this as combination processing. Codes to which billed services combine are usually a superset of the billed codes. An example would be a set of laboratory codes that are all contained within a single panel or multichannel test. Less frequently, Anthem will combine billed codes into a code which is not a superset by strict definition, but does represent the value of the combined services billed. In no case will Anthem reimburse more in aggregate for individually billed codes that are part of a panel, than what Anthem reimburses for the panel code alone, regardless of whether all individual codes that make up the panel are billed. Provider will bill all lab services on one Claim when incurred on the same date of service. Global Processing For some services (typically surgical services), Anthem imposes global processing rules, wherein some services (typically evaluation and management services) are incidental to other services (typically procedural services) when provided within a defined time period, relative to the procedural service. Anthem follows CMS conventions regarding global designations and time periods for major and minor surgery. The following services are also not eligible for separate reimbursement when performed during the global postoperative period of the related surgical procedure, except as noted below: Incision and drainage of abscess, simple/single/complicated or multiple (10060-10061)* Incision and drainage of hematoma, seroma, or fluid collection (10140)* Puncture aspiration of abscess, hematoma, bulla, or cyst (10160)* Incision and drainage, complex postoperative wound infection (10180)* Adjustment of gastric band diameter via subcutaneous port by infection or aspiration of saline (S2083)* * Typically, the procedures asterisked above are performed in an office setting. However, if such an asterisked procedure requires a return to the operating room during the postoperative period, modifier 78 should be appended tothecodefortheprocedure. Repair of a surgical incision (CPT codes 12001-13153) is generally included in the global surgical package. These codes will not be reimbursed by Anthem, except where specific CPT code book reporting guidelines define their use in conjunction with lesion excisions. Form No.: Plan CompensationScheduleAttachment (03/01/13) page 5

Age/Sex Restrictions Some services (e.g., hysterectomy) are allowed for only one sex. Some services (e.g., neonatal intensive care) are allowed only for certain age ranges. History Edits These edits apply to once-in-a-lifetime procedures, i.e., appendectomy. They also apply to items like drugs or supplies that may have monthly limits. In addition, history edits may apply to certain codes, which denote services for a specified time period (e.g., weekly or monthly radiology or renal dialysis). Health Services Review Some services may be non-covered, or only partially covered if they do not have a health service review. Venipuncture (Blood Collection) In addition to a covered laboratory blood test, Anthem will reimburse one venipuncture code per member per date of service. Therefore, if more than one of the following codes is reported for the same member on the same date of service, the second code will be denied as not eligible for separate reimbursement. The venipuncture codes are: 36415, 36416, S9529 Lab Handling and Conveyance Anthem considers the handling and conveyance of a laboratory specimen, to be included in a provider s management of a patient. Therefore codes 99000, 99001 are not eligible for separate reimbursement. Modifier 26 with Pathology and Laboratory Codes Modifier 26 is reimbursable only when billed for select pathology and laboratory CPT codes that require a separately identifiable professional interpretation beyond the technical component. The list of pathology and laboratory codes for which Modifier 26 may be reimbursed may change from time to time and is based upon the CMS National Physician Fee Schedule Relative Value File. Direct Payment for Laboratory Services Laboratory services must be billed to Anthem by the provider of service. This means that laboratory services provided intheprovider sofficeshouldcontinuetobebilledbytheprovider.however,servicesprovidedbyanoutside laboratory must be billed directly to Anthem by the laboratory. For purposes of this Agreement, an outside laboratory must be a reference laboratory or a laboratory in which the referring provider or provider group has no financial or ownership interest, and which accepts samples for review from all providers. No Reimbursement for Technical Only or Complete Service for a Hospital Inpatient or Outpatient Physicians who provide clinical lab, pathology, radiology or other diagnostic testing services to hospital inpatients or outpatients shall only be reimbursed for the professional component fee allowance (when the code has a separate professional component RVU assigned based on CMS quidelines). There will be no reimbursement to the physician for the technical component only, or the complete service. Such reimbursement has been included in the payment to the hospital. Reimbursement for LDL Cholesterol In cases where a Lipid Panel, code 80061 is rendered, and the LDL cholesterol measurement is calculated based on subtracting the HDL cholesterol measure from the Total cholesterol measure, no additional reimbursement is provided. Separate reimbursement for the LDL cholesterol (code 83721) will only be provided when there is a direct measurement. Reimbursement for Qualitative Drug Screening Qualitative drug screening tests are used to detect the presence of drugs or drug classes in the body. They provide a positive or negative result rather than specific measurements of the level of a drug or drugs. Testing may involve CLIA waived methodologies (such as test cup, test strip, cassette, or card), moderate complexity test methodologies (i.e., Form No.: Plan CompensationScheduleAttachment (03/01/13) page 6

instrumented equipment specified by FDA as moderate complexity), and high complexity test methodologies (i.e., testing systems or processes specified by FDA as high complexity). High complexity testing requires a CLIA Certificate of Registration, Compliance, or Accreditation, and is generally held by independent labs and hospital labs. Existing Codes in CPT and HCPCS related to qualitative drug screening are as follows: 80100 Drug screen, qualitative; multiple drug classes chromatographic method; each procedure 80101 Drug screen, qualitative; single drug class method (e.g. immunoassay, enzyme assay), each drug class 80104 Drug screen, qualitative; multiple drug classes other than chromatographic method, each procedure G0431 Drug screen, qualitative; multiple drug classes by high complexity test method (e.g. immunoassay, enzyme assay) per patient encounter G0434 Drug screen, other than chromatographic; any number of drug classes by CLIA waived test or moderate complexity test, per patient encounter Codes 80100, 80101, and 80104 are not reimbursable and will be denied. Qualitative drug screening is only reimbursable using codes G0431 and G0434. Both codes G0431 and G0434 are eligible for one unit of reimbursement per date of service. Use of code G0431 is limited to only high complexity testing, and documentation of FDA approved complexity level for instrumented equipment utilized, and CLIA Certificate of Registration, Compliance, or Accreditation as a high complexity lab, may be requested as a condition for reimbursement. New Patient Evaluation and Management Service A new patient is one who has not received any professional services from the physician or another physician of the exact same specialty and subspecialty who belongs to the same group practice, within the past three years. Anthem will deny billings for inappropriate use of a new patient visit code within the three year time period when the provider is the same, or different, and has the same specialty and group tax ID as the provider of the original new patient visit. Therapeutic, Prophylactic or Diagnostic Injections Therapeutic, prophylactic or diagnostic injection, code 96372, is considered incidental when billed with any of the following: Immunization Administration Codes 90460 90474; Vaccine codes 90581 90749; Allergy Immunotherapy codes 95115-95117 and Chemotherapy Administration codes 96401 96402. Per CPT billing guidelines, immunization administration codes 90460 90474 should be used when the provider is administering a vaccine/toxoid (code range 90581 90749). Modifier 51 should not be appended to the vaccine/toxoid code. Allergy immunotherapy injections should be billed with CPT codes 95115 95117. Anti-neoplastic nonhormonal chemotherapy should be billed with CPT code 96401. Anti-neoplastic hormonal chemotherapy should be billed with CPT code 96402. Injection and Infusion Reimbursement in a Facility Setting The 2012 AMA CPT reporting guidelines specify that CPT codes for Hydration, Therapeutic, Prophylactic and Diagnostic Injections and Infusions and certain Chemotherapy Administration, are not intended to be reported by the physician in the facility setting. Those codes are as follows: 96360-96379, 96401, 96402, 96409-96425, 96521-96523. Claims for these codes that are billed with a facility place of service will not be reimbursed. Facility settings include inpatient hospital, outpatient hospital, emergency department, ambulatory surgical center, birthing center, military treatment facility, skilled nursing facility, inpatient behavioral health facility, outpatient behavioral health facility, and behavioral health residential treatment facility. Bundled Services and Supplies There are numerous services and supplies that are not eligible for separate reimbursement when reported by a professional provider. These services and /or supplies may be reported with a primary service or as a stand alone service. In most cases, services rendered without direct (face-to-face) patient contact are considered to be an integral component of the overall medical management service and are not eligible for separate reimbursement. In addition, modifier 59 will not override the denial for the bundled services and or supplies listed below. Form No.: Plan CompensationScheduleAttachment (03/01/13) page 7

These bundled services and supplies may include, but are not limited to: 1. administrative services requiring physician documentation (e.g. recertification, release forms, physical/camp/school/daycare forms, etc.) 2. all practice overhead costs, such as heat, light, safe access, regulatory compliance including CDC and OSHA compliance, general supplies (paper, gauze, band aids, etc.), infection control supplies, insurance (including malpractice insurance), collections 3. AmniSure ROM (rupture of fetal membranes) test 4. application of a modality to one or more areas; hot or cold packs 5. collection/analysis of digitally/computer stored data 6. complex chronic care coordination services 7. copies of test results for patient 8. coronary therapeutic servicesand proceduresadd-on codes 9. costs to perform participating provider agreement requirements, such as prior authorizations, appeals, notices of non coverage 10. determination of venous pressure 11. DMEand other delivery and/or set up fees 12. equipment and/or enhanced technology as part of a procedure, test, or treatment (e.g., robotic surgical systems, radiation oncology treatment tracking systems including Clarity ) 13. global fee for urgent care centers 14. handling and/or conveyance fees 15. heparin lock flush solution or kit for non therapeutic use 16. hospitalist services (additional unspecified) 17. hospital mandated on-call service 18. insertion of a Bakri balloon for treatment of post-partum hemorrhage 19. insertion of a pain pump by the operating physician during a surgical procedure 20. online assessment and management by a qualified nonphysician health care professional 21. outpatient Healthcare Common Procedural CodingSystem Level II (HCPCS)? C codes 22. peak expiratory flow rate 23. photography 24. pharmacy and other dispensing services and/or supply fees, etc. 25. physician care plan oversight 26. physician interpretation and report of molecular pathology procedures 27. physician standby service 28. placement of an occlusive device into a venous or arterial access site, post op/procedural 29. post op follow up visit during the global period for reasons related to the original surgery 30. preparation of fecal microbiota for instillation, including assessment of donor specimen 31. prescriptions, electronic, fax or hard copy, new and renewal, including early renewal 32. prolonged physician in-patient service 33. prolonged E/M service before and after direct patient care 34. qualitative drug screen testing (Refer to Qualitative Drug Screen Testing Policy) 35. pulse oximetry 36. Reporting only codes including Current Procedural Terminology (CPT ) Category II supplemental tracking codes for performance measurement, HCPCS? Quality Measure codes, and HCPCS? Functional Limitation codes Form No.: Plan CompensationScheduleAttachment (03/01/13) page 8

37.reviewofmedicalrecords 38. routine post surgical services such as dressing changesand suture removal 39. spinal surgery only graft (allograft, morselized) 40. spinal surgery only graft (autograft, same incision) 41. tat laboratory request 42. state or federal government agency supplied vaccines 43. surgical/procedural suppliesand materials supplied by the provider rendering the primary service (e.g. surgical trays, syringes, needles, sterile water, etc.) 44. team conferences to coordinate patient care 45. telephone consultations with the patient, family members, or other health care professionals 46. transitional care management services 47. travel allowance for laboratory specimen pick-up * 48. treatment planning and care coordination management for cancer treatment 49. 3D rendering of imaging studies The following table identifies by code some of the procedures and supplies that are described above. The inclusion or exclusion of a specific code does not indicate eligibility for coverage under all circumstances. This table is provided as an informational tool only, to help identify some of the procedures described above. 0185T 94760 99060 99377 A4263 G0333 S0310 15850 94761 99070 99378 A426 G0452 S0353 20930 97010 99090 99379 A4270 H0048 S0354 20936 98966 99091 99380 A4300 J1642 S2900 44705 98967 99339 99441 A4470 P9603 S3600 76376 98968 99340 99442 A4480 P9604 S3601 76377 98969 99356 99443 A4550 Q0092 S3628 80100 99000 99357 99487 A4649 Q0510 S8055 80101 99001 99358 99488 A4650 Q0511 S8110 80104 99002 99359 99489 A4770 Q0512 S8301 84112 99024 99360 99495 A9901 Q0513 S9083 90885 99026 99366 99441 G0175 Q0514 S9088 90887 99027 99367 99496 G0179 S0220 S9381 90889 99053 99368 A4216 G0180 S0221 S9430 93770 99056 99374 A4218 G0182 S0260 94005 99058 99376 A4262 G0269 S0302 Also, C1300 C9899, and G0908 G9140. 3D Rendering of Imaging Studies The Health Plan considers 3D rendering of imaging studies to be a technology and technique improvement that represents an aid to the physician via computer generated real-time study interpretation and decision support. CPT codes 76376 and 76377 for 3D rendering are considered included as part of the imaging procedure reimbursement, and are not eligible for separate reimbursement even when reported with modifier 59. Bundled Supplies with Injection and Infusion Administration Services related to intravenous infusion such as local anesthesia, IV start or access to a catheter or port, and flushing procedures should not be reported separately, and are not eligible for separate reimbursement. Materials and supplies used during the course of the administration of intravenous infusion or for injections are considered to be an integral component of the reimbursement for the services provided and are not reimbursed separately. These supplies include but are not limited to: needlesand syringes needle free injection devices Form No.: Plan CompensationScheduleAttachment (03/01/13) page 9

sterile water, saline, heparin, and/or dextrose diluent/flush refill kits disinfectant wipesand agents such asalcohol, peroxide, iodine, Betadine, and phisohex, tape,gauze,gloves,trays,etc. ambulatory infusion pumps The following supplies are incidental to injection and infusion codes (96360 to 96379, 96401 to 96549), and will not be separately reimbursed: A4206 A4212 A4221 A4246 A4450 A4657 A6217 A6257 J1642 A4207 A4213 A4222 A4247 A4552 A4927 A6218 E0776 S1015 A4208 A4215 A4223 A4248 A4455 A4928 A6219 E0779 S1016 A4209 A4216 A4244 A4305 A4550 A4930 A6220 E0780 A4210 A4220 A4245 A4306 A4649 A6216 A6221 E1399 Overhead Expenses for Office-Based Services Reimbursement to Provider for office-based surgery includes all expenses involved in the performance of the surgery, including but not limited to surgical trays, disposable supplies, reusable surgical instruments, monitoring equipment, office or surgical space, nursing or other surgical aides, and miscellaneous overhead. No reimbusement will be made separately to vendors that the provider may contract with or otherwise have agreement with to furnish any of these expense items during performance of a surgery. The office-based fee allowance is inclusive of all necessary overhead expenses. In addition, reimbursement to Provider for office-based diagnostic testing includes all expenses involved in the performance of the test, including supplies, overhead, and equipment utilized to render such tests. For example, office-based reimbursement for diagnostic sleep studies and CPAP titration (CPT 95810-95811) would include supplies and equipment such as the CPAP equipment, humidifier, face mask, headgear, tubing, filters, etc. AfterHourChargesintheOfficeSetting Anthem s definition of after hours is between 5 p.m. and 8:30 a.m. weekdays, and anytime on weekends and holidays. After hours charges are only reimbursed for services in the office setting. Intermediate Repair in Conjunction with Excision of Non-Facial Benign Lesions Intermediate repair codes 12031, 12032, 12041, 12042 are considered incidental to excision of non-facial benign lesion codes with excised diameter of 1.0 cm or less each (codes 11400, 11401, 11420, and 11421). This rule does not apply to excision of malignant lesions or lesions of the face, ears, eyelids, nose, lips and/or mucous membranes. Use of modifier 59 will not override these incidental edits. Anesthesia Reimbursement Services involving the administration of anesthesia are to be reported by the use of the anesthesia five-digit procedure codes (00100 01999) plus an anesthesia modifier code (AA, AD, G8, G9, P1, P2, P3, P4, P5, P6, QK, QS, QX, QY, QZ, 23, 47). No reimbursement will be allowed for anesthesia services billed with a CPT procedural code (10021 69990). When a provider personally performs both the surgical service and the anesthesia service, the anesthesia service will be reimbursed at 50% of Anthem s allowance. When the provider performs the surgical service, and the anesthesia is rendered by a CRNA who is employed by or under contract with the provider, the anesthesia service will be reimbursed at 50% of Anthem s allowance to the provider who rendered the surgery. Reimbursement for administration of anesthesia is determined by multiplying the sum of the base units for the anesthesia code, and the time units reported, by the anesthesia conversion factor. Anesthesia time units are defined as each 15- minute period of administration of anesthesia. The reimbursement will represent payment for both the supervising anesthesiologist and the CRNA services. In the event Provider bills for both the anesthesiologist medical direction, and the CRNA services as two separate claim lines, the CRNA service will be denied. When two or more anesthesia procedure codes are billed during the same operative session, reimbursement of base units will only be made for the anesthesia procedure code with the highest base units. Reimbursement of the time units will be made for the combined total of administration of anesthesia for all procedures rendered. Form No.: Plan CompensationScheduleAttachment (03/01/13) page 10

Management of intravenous patient controlled analgesia subsequent to the initial insertion procedure should not be reported separately and will not be reimbursed. Management of intravenous patient controlled analgesia is the responsibility of the surgeon as part of the post-operative care and is included in the global surgery fee allowance. Global Period Processing for Anesthesia: Global reimbursement for an anesthesia service includes one day preoperative evaluation and management (E/M) services and 10 day post operative E/M services. The 10 day post operative period includes any E/M services that are a follow-up to the general anesthesia service, as well as any E/M services relative to post operative pain management for the surgical episode. The 10 day post operative period will apply to the anesthesiologist or other qualified health care professional who performed the general anesthesia, or to other providers in the same anesthesia provider group. Moderate (Conscious) Sedation Drugs routinely used with conscious sedation such as meperidine, fentanyl citrate, droperidol, and morphine sulfate will not be reimbursed separately when the service is identified in Appendix G of the CPT manual as inclusive of conscious sedation. These drugs include, but are not limited to: J1170, J1810, J2175, J2180, J2250, J2270, J2271, J2275, J2300, J2310, J2410, J2550, J2560, J3010 and J3360. Nerve Block billed in addition to General Anesthesia A nerve block billed on the same day as general anesthesia by the same provider, for non-obstetrical cases, will be reimbursed at 50% of the Anthem Rate. A nerve block billed on the same day as obstetrical anesthesia by the same or different provider, is included in the maternity anesthesia case rate, and is not subject to additional reimbursement. Nerve block codes subject to this reimbursement guideline are 62310 62318, and 64400 64530. Note: ClaimsXten will pay both at 100%. Telemedicine Telemedicine services, as it pertains to the delivery of health care services, means the use of interactive audio, video, or other electronic media used for the purpose of diagnosis, consultation, or treatment. Telemedicine services do not include an audio-only telephone conversation, electronic mail message, or facsimile transmission. Telephone only and electronic mail message codes not eligible for separate reimbursement are 98966, 98967, 98968, 98969, 99441, 99442, 99443, 99444. Coded Service Identifiers Additions and Deletions Coded Service Identifier additions occur annually for CPT codes, and quarterly for HCPCS codes. When such additions are made, those Coded Service Identifiers will automatically be added to Anthem s Fee Schedule (i.e., if they are contractually covered in any instances) on the effective date of the addition as published by the AMA each year for CPT codes, and as published by the Centers for Medicare & Medicaid Services (CMS) on a quarterly basis for HCPCS codes. Payment hereunder for such added Coded Service Identifiers shall equal Anthem s conversion factor as of that date multiplied by the CMS relative value unit which has been assigned to the new code. Anthem will implement such added Coded Service Identifiers with frequency limits, and multiple procedure, incidental, combination and global processing rules analogous to those used for established Coded Service Identifiers. Coded Service Identifier deletions occur annually for CPT codes, and quarterly for HCPCS codes. When such deletions are made, those Coded Service Identifiers will automatically be cancelled from Anthem s Fee Schedule on the effective date of the deletion as published by the AMA each year for CPT codes, and as published by CMS on a quarterly basis for HCPCS codes. Claims incurred after the cancellation date, for those deleted Coded Service Identifiers, will no longer be accepted or processed, but will instead be rejected. The matters described above concerning Coded Service Identifier additions and deletions shall take place automatically and do not require any notice or disclosure to Provider or any contract amendment. Injectible/Infusible Drug Allowances Reimbursement for injectible drugs (i.e., "J," "Q," and "S" codes only) will be handled in the following manner. Anthem will utilize the drug pricing file as published by CMS as a basis for establishing individual procedure code reimbursement. Anthem s actual allowance will be calculated at 100% of the published fee in the drug pricing file. Anthem will automatically update its allowances for injectible/infusible drugs in accordance with CMS quarterly updates to the drug pricing file, except that any retroactive adjustments to allowances made by CMS shall be Form No.: Plan CompensationScheduleAttachment (03/01/13) page 11

inapplicable to Anthem s allowances and payment responsibility. In the event there are multiple fees published for a procedure code, Anthem will utilize the lowest fee that is published. Fee allowances not on the drug pricing file* will be based on AWP 16%, where AWP is identified through Wellpoint s Pharmacy Benefit Manager. Anthem reserves the discretion to increase drug fees above the level established by the methodology described in the preceding paragraph, as market or business conditions may warrant. The matters described above concerning updating of injectible/ drug allowances shall take place automatically and do not require any notice or disclosure to Provider or any contract amendment. *Drug pricing file is known as Payment Allowance Limits for Medicare Part B Drugs. Vaccine Allowances Anthem reserves the discretion to increase reimbursement for vaccines (i.e., 90476 to 90749) as market revisions in their acquisition cost may warrant. The matters described above concerning updating of vaccine allowances shall take place automatically and do not require any notice or disclosure to Provider or any contract amendment. Therapy Reimbursement Rules for Manual Medical Intervention and Evaluation and Management Services Spinal manipulation codes billed by licensed providers accrue towards the Manual Medical Intervention benefit when this benefit is in place for Covered Individuals. This would include codes 98940-98943 and 98925-98929. In addition, codes 97140 and 97124 also accrue towards the Covered Individual s manual medical intervention benefit cap when billed by licensed providers. The Manual Medical Intervention benefit is separate from the Covered Individual s physical and/or occupational therapy benefit. New patient evaluation and management codes submitted by licensed MDs, DOs and Chiropractors are reimbursable when submitted with time dependent procedures and spinal manipulation codes on the same date of service. Established patient evaluation and management codes submitted by licensed MDs, DOs and Chiropractors will be denied as incidental (not eligible for reimbursement). Form No.: Plan CompensationScheduleAttachment (03/01/13) page 12

Modifiers That Affect Allowances Processing rules apply to PAR/PPO, HMO, Medicare Advantage unless otherwise noted. Modifier Description Processing 22 Increased Procedural Services Pends for Medical Review. Medical records required. Additional payment made on a case-by-case basis when supported by medical documentation. 120% of allowance if warranted after review) 23 Unusual anesthesia (normally not required) Paid at anesthesia allowance. 25 Significant, Separately IdentifiableEvaluation and Management Services by thesamephysician on thesame Day of theprocedure or Other Service E&M base fee allowed when appropriately billed in conjunction with a more substantial procedure. Supporting documentation may be requested as part of the post payment review program. 26 Professional Component Professional feeallowance 27 Multiple Outpatient Hospital E/M encounters on thesame date No reimbursement. Inappropriate for professional providers. 50 Bilateral Procedure 150% of allowance Note: Bilateral Procedures or Services Code one (1) in Days/Units field (24G) If more than 2 unitsapply to abilateral procedure or service, record the total number of units in the Days/Units field (24G). DO NOT USE MODIFIER 50. 52 Reduced Services 50% of allowance 53 Discontinued Procedure 50% of allowance 54 Surgical CareOnly 70% of allowance 55 Postoperative Management Only 20% of allowance 56 Preoperative Management Only 10% of allowance 59 Distinct Procedural Service Modifier 59 will override bundling edits when billed in accordance with AMA CPT reporting guidelines. See list of exceptions as posted on Anthem.com. Do not bill with CCI 0 modifier indicator edits. 62 TwoSurgeons 63% of allowance paid to each surgeon 63 Procedure performed on infant less than 4 kg 120% of allowance Medicare Advantage (PAR/PPO) Not Applicable. 66 Surgical Team Pends for medical review. (Fee divided by number of surgeons.) 73 Discontinued Out-Patient Hospital or Ambulatory Surgery Center No reimbursement. Inappropriate for professional providers. procedure prior to administration of anesthesia 74 Discontinued Out-Patient Hospital or Ambulatory Surgery Center No reimbursement. Inappropriate for professional providers. procedure after administration of anesthesia 76 Repeat Procedure or Service by SamePhysician 100% of allowance 78 Unplanned return to the Operating/ProcedureRoom by Same 70% of allowance Physician for arelated Procedure During thepostoperativeperiod 80 Assistant Surgeon 16% of surgical allowance if procedure indicates assistant surgeon is covered. 81 Minimum Assistant Surgeon 16% of surgical allowance if procedure indicates assistant surgeon is covered. 82 Assistant Surgeon (Resident surgeon not available.) 16% of surgical allowance if procedure indicates assistant surgeon is covered. 90 Reference (outside) Lab Deny- Must be billed by the provider of services. AD Medical supervision by a physician; more than 4 concurrent Paid at 50% anesthesiaallowance. anesthesia procedures AS Physician assistant, nurse practitioner or clinical nursespecialist 14% of surgical allowance services for assistant at surgery GQ Viaasynchronous telecommunications systems Deny Non Covered GT Via interactive audio-visual telecommunication systems 100% of allowance MS Six-month maintenanceand servicing DME PAR/PPO- Pends for Case Management Review HMO- This service is not covered under the provider agreement Medicare Advantage (PAR/PPO) 100% of fee allowance (1 month rental allowance.) P3 A patient with severesystemic disease 108% of allowance P4 A patient with severesystemic disease that is a constant threat to 112% of allowance life P5 A moribund patient who is not expected to survive without the 116% of allowance operation QF Prescribed amount of oxygen is greater than four liters per minute HMO Pends for Medical Review. Medical Records required PAR/PPO Not Applicable Medicare Advantage (PAR/PPO) Not Applicable QG Prescribed amount of oxygen is greater than four liters per minute HMO Pends for Medical Review. Medical Records required PAR/PPO Not Applicable Medicare Advantage (PAR/PPO) Not Applicable QH Oxygen conserving device is being used with oxygen delivery system Deny Investigational/Non-Covered Medicare Advantage (PAR/PPO) Not Applicable QX CRNA service with medical direction by a physician 50% of allowance Note: Use only when billing for thesupervision of a hospital employed CRNA. Do not reduce anesthesia time or charges. The applicable reductions will be taken automatically. TC Technical Component Technical fee allowance Form No.: Modifier Table (03/1/2013) page 13

Professional Provider Schedule of Allowances March 1, 2013 Footnotes This schedule represents the base schedule of allowances applicable to the range of services expected to be rendered by you on a routine basis as of the date above and applies only to non-capitated services. The inclusion of an allowance does not imply that the service is covered. Also, there are many factors that may impact the actual amount reimbursed for a service. The patient s contract benefits will be applied (e.g., co-payment, co-insurance, and deductibles). All contract payment rules and medical policies affecting reimbursement also apply. Global time period, multiple surgery payment rules, incidental processing, combination processing, limits on the service, medical necessity, and pre-existing review may be applied. Lastly, the procedure description presented here is not complete. For complete nomenclature, a current edition of the AMA CPT-4 or HCPCS manual should be used. Reproduction and disclosure of this schedule is strictly forbidden. The procedures listed for each specialty represent approximately 80-95% of the Health Plan s aggregate payment for that specialty based on 3rd quarter 2011 paid claims. This fee schedule is applicable only to providers physically practicing in the locations in your application or already on file with Anthem. In the event that your practice has, builds, purchases, or otherwise acquires an office or location, by any means whatsoever, outside of your current locations, then another fee schedule may apply for that area. To get a copy of such other fee schedule, please contact your Network Manager at the appropriate phone number in the cover letter. Legend: Modifier - "TC" equals the technical component only. "26" equals the professional component only. "NU" equals medical equipment purchase. "RR" equals medical equipment rental. Office Differential - If a procedure is listed with a Yes, then the listed fee represents the allowance for rendering the service in the provider s office. IC - Stands for Individual Consideration. If a procedure is listed with an "IC," then reimbursement is individually considered and may require the submission of medical records prior to payment. LSS - Stands for Limit, Secondary, and Subsequent. It defines the maximum number of times a procedure will be reimbursed, and the percentage payment for the second and subsequent occurrences of the same procedure, when rendered on the same day. For example, for Limit, a "1" means reimbursement will be made for a single unit per provider, per patient, per day; a "2" means reimbursement will be made for two units; a "3" means reimbursement will be made for three units; a "U" means reimbursement may be based on a daily, monthly, or annual unit maximum. The limit for specific procedures with a "U" will be furnished upon request. For Secondary and Subsequent reimbursement, a "1" equals 100%, a "2" equals 50%, and a "4" equals 25%. For example, an LSS of "324" means the maximum units allowed equals three, where the first unit is reimbursed at 100%, the second unit is reimbursed at 50%, and the third unit is reimbursed at 25%. Form No.: Footnotes (3/1/2013) page 14

Physician Office Lab List for Virginia HMO (HealthKeepers/HealthKeepers Plus) PRIMARY CARE PHYSICIANS 80047 BASIC METABOLIC PANEL (Calcium, ionized) 85004 BLOOD COUNT; AUTOMATED DIFFERENTIAL 80048 BASIC METABOLIC PANEL (Calcium, total) 85007 BLOOD COUNT; MANUAL DIFFERENTIAL 80051 ELECTROLYTE PANEL 85008 MANUAL BLOOD SMEAR EXAMINATION 81000 URINALYSIS, BY DIPSTICK OR TABLE 85009 DIFFERENTIAL WBC COUNT, BUFFY 81001 AUTOMATED, WITH MICROSCOPY 85013 SPUN MICROHEMATOCRIT 81002 URINALYSIS, BY DIPSTICK OR TABLET 85014 OTHER THAN SPUN HEMATOCRIT 81003 URINALYSIS, BY DIPSTICK OR TABLE 85018 HEMOGLOBIN 81005 URINALYSIS; QUALITATIVE OR SEMIQU 85025 HEMOGRAM AND PLATELET COUNT, 81007 URINALYSIS; BACTERIURIASCREEN, EX 85027 HEMOGRAM AND PLATELET COUNT, 81015 MICROSCOPIC ONLY 85032 MANUAL CELL COUNT (ERYTHROCYTE 81020 URINALYSIS, QUALITATIVE OR SEMIQU 85041 RED BLOOD CELL (RBC) 81025 URINE PREGNANCY TEST, BY VISUAL C 85044 RETICULOCYTE COUNT, MANUAL 82247 BILIRUBIN; TOTAL 85045 RETICULOCYTE COUNT, FLOW CYTO 82248 BILIRUBIN; DIRECT 85046 BLOOD COUNT; RETICULOCYTES, HEMOG 82270 BLOOD, OCCULT; FECES, SCREENING, 85048 WHITE BLOOD CELL (WBC) 82272 BLOOD, OCCULT, BY PEROXIDASE ACTIV 85610 PROTHROMBIN TIME; 82274 BLOOD, OCCULT, BY FECAL HEMOGLOBIN 86308 HETEROPHILE ANTIBODIES; SCREENING 82310 CALCIUM; TOTAL 86485 SKIN TEST; CANDIDA 82374 CARBON DIOXIDE (BICARBONATE) 86580 TUBERCULOSIS, INTRADERMAL 82435 CHLORIDE; BLOOD 86586 UNLISTED ANTIGEN, EACH 82565 CREATININE; BLOOD 87081 CULTTURE, PRESUMPTIVE, PATHOGENIC ORGANISMS, SCREENING ONLY 82947 GLUCOSE; QUANTITATIVE 87207 SPECIAL STAIN FOR INCLUSION BODIES OR 82948 BLOOD, REAGENT STRIP 87210 WET MOUNT WITH SIMPLESTAIN, 82951 TOLERANCE TEST (GTT), THREE 87220 TISSUE EXAMINATION FOR FUNGI (EG, 82952 TOLERANCE TEST, EACH ADDITIONAL 87430 STREPTOCOCCUS, GROUP A 82962 GLUCOSE, BLOOD, BYGLUCOSE MONITOR 87804 INFECTIOUS AGENT ANTIGEN DETECTION 84132 POTASSIUM; SERUM 87880 STREPTOCOCCUS, GROUP A 84295 SODIUM; SERUM 88720 BILIRUBIN, TOTAL TRANSCUTANEOUS 84520 UREA NITROGEN; QUANTITATIVE Form No.: Physician Office Lab List (03/01/13) page 15

Physician Office Lab (POL)List for Virginia HMO (HealthKeepers/HealthKeepers Plus) SPECIALIST PHYSICIANS THIS COLUMN APPLIES TO ALL SPECIALISTS CARDIOLOGY ONLY 80047 BASIC METABOLIC PANEL (Calcium, ionized) 85610 PROTHROMBIN TIME 80048 BASIC METABOLIC PANEL (Calcium, total) DERMATOLOGY ONLY 80051 ELECTROLYTE PANEL 88331 PATHOLOGY CONSULTATION DURING SURGERY; FIRST TISSUE BLOCK, WITH FROZEN SECTION(S), SINGLESPECIMEN 81025 URINE PREGNANCY TEST, BY VISUAL 88332 EACH ADDITIONAL TISSUE BLOCK W/FROZEN SECTIONS(S) 82270 BLOOD, OCCULT (e.g. GUAIAC), SINGLE ENDOCRINOLOGY ONLY DETERMINATION 82272 BLOOD, OCCULT,(e.g. GUAIAC), 1-3 82948 BLOOD, REAGENT STRIP SIMULTANEOUS DETERMINATIONS 82274 BLOOD, OCCULT, BY FECAL HGB 82962 GLUCOSE, BLOOD, BYGLUCOSE MONITOR 82310 CALCIUM; TOTAL HEMATOLOGY/ONCOLOGY ONLY 82374 CARBON DIOXIDE (BICARBONATE) 85002 BLEEDING TIME 82435 CHLORIDE; BLOOD 85014 OTHER THAN SPUN HEMATOCRIT 82565 CREATININE; BLOOD 85025 HEMOGRAM AND PLATELET COUNT, 82947 GLUCOSE; QUANTITATIVE (except strip) 85027 HEMOGRAM AND PLATELET COUNT, 83861 TEAR OSMOLARITY 85048 WHITE BLOOD CELL (WBC) 81000 URINE DIPS 84132 POTASSIUM; SERUM, PLASMA OR WB 84295 SODIUM; SERUM, PLASMA OR WHOLE BL INFECTIOUS DISEASE ONLY 84520 UREA NITROGEN; QUANTITATIVE 85025 HEMOGRAM AND PLATELET COUNT, 85004 BLOOD COUNT; AUTOMATED DIFFERENTIAL WBC COUNT 85027 HEMOGRAM AND PLATELET COUNT, 85013 SPUN MICROHEMATOCRIT 85651 SEDIMENTATION RATE, ERYTHROCYTE; 86485 SKIN TEST; CANDIDA NEPHROLOGY & UROLOGY ONLY 86580 TUBERCULOSIS, INTRADERMAL 81000 URINALYSIS, BY DIPSTICK OR TABLET, NON-AUTOMATED, W/ MICROSCOPY 87077 CULTURE, BACTERIAL DEFINITIVE (See NOTE) 81001 SAME, AUTOMATED, WITH MICROSCOPY 81002 SAME, NON-AUTOMATED, W/OUT MICROSCOPY 87081 CULTURE, PRESUMPTIVE, PATHOGENIC OR 81003 SAME, AUTOMATED, W/OUT MICROSCOPY GANISMS, SCREENING ONLY 81005 URINALYSIS; QUALITATIVE OR SEMIQUANTITATIVE 87207 SPECIAL STAIN FOR INCLUSION BODIES 85014 BLOOD COUNT, HEMOGLOBIN-NEPHROLOGY ONLY 87210 WET MOUNT FOR INFECTIOUSAGENTS 85018 BLOOD COUNT, HEMATOCRIT-NEPHROLOGY ONLY 87220 TISSUE EXAM BY KOH SLIDE OFSA PULMONARY DISEASE ONLY 82803 GASES, BLOOD, ANY COMBINATION OF 87804 INFECTIOUS AGENT ANTIGEN DETECTION: INFLUENZA 87880 INFECTIOUS AGENT ANTIGEN DETECTION: STREP, Group A Eff.5/23/11 82810 GASES, BLOOD, O2 SATURATION ONLY, 88172 EVALUATION OF FINE NEEDLE ASPIRATE REPRODUCTIVE ENDOCRINOLOGY & GENERAL SURGERY ONLY 88173 INTERPRETATION AND REPORT 84703 GONADOTROPIN, CHORIONIC (HCG); QUALITATIVE NOTE: 87077 will be reimbursed fee-for-service only if billed with the following diagnosis codes: 041.86, 530.81, 531.20, 532.00, 535.00, 787.02 Form No.: Physician Office Lab List (03/01/13) page 16

OTHER REIMBURSEMENT INFORMATION Medicare Advantage Reimbursement For Covered Services provided to Covered Individuals enrolled under Anthem s Medicare Advantage Health Benefits Plans, Anthem will reimburse the provider the lesser of the provider s charge or 100% of the then current Virginia Medicare fee schedule. The amounts payable by Anthem shall be reduced by any cost shares for which the Covered Individual is responsible under the terms of his/her Medicare Advantage Health Benefits Plan. Fee Schedule Implementation Certain Anthem Rates are based on payment rates that are developed and/or administered by other entities ( Other Payment Entities ) such as governmental payers and vendors. For example, Anthem Rates may be expressed as a percentage of CMS state-specific fee schedules or pharmaceutical rates. In these situations, when the Other Payment Entities change their payment rates, the parties recognize and agree that Anthem s payment systems cannot be modified immediately to make the appropriate adjustment to the Anthem Rates by the Other Pay Entities effective date, but must instead be modified during a timeframe of sufficient length to allow for the loading of payment system changes and updates, including changes and updates that allow for the recognition of new fees and codes. Anthem shall use commercially reasonable efforts to load such payment changes as quickly as practicable following the release date of such changes by the Other Payment Entities, however, unless otherwise required by law or applicable regulation, any updates to the Anthem Rates that are necessary because of payment changes by Other Payment Entities shall be made effective no later than sixty (60) days after Anthem s receipt of such payment changes from the Other Payment Entities or the Other Payment Entities effective date, whichever is later Claims processed by Anthem prior to Anthem s implementation of the new Anthem Rates and after the Other Payment entities effective date shall not be reprocessed. The Plan will automatically update its allowances for injectible/drugs in accordance with CMS quarterly updates to the Drug Pricing File, except that any retroactive adjustments to allowances made by CMS shall be inapplicable to Plan s allowances and payment responsibility. Compensation-Medicare Medicaid Dual Integration A. For Covered Services reimbursed by Medicare Fee for Service ("FFS"), the reimbursement amount is one hundred percent (100%) of the prevailing state Medicare FFS rate minus one hundred percent (100%) of the applicable Medicare FFS beneficiary Cost Share for the applicable service ( Dual Medicare Amount ) shall be compared to one hundred percent (100%) of the applicable state Medicaid fee schedule. (a) If the Dual Medicare Amount exceeds one hundred percent (100%) of the applicable state Medicaid fee, reimbursement amount equals the Dual Medicare Amount. (b) If the Dual Medicare Amount is less than one hundred percent (100%) of the applicable state Medicaid fee, reimbursement amount equals the lesser of - i) One hundred percent (100%) of the prevailing state Medicare FFS rate; or - ii) One hundred percent (100%) of the applicable state Medicaid fee. B. For Covered Services reimbursed by Medicaid FFS, reimbursement amount equals 100% of the applicable state Medicaid fee. C. For Covered Services reimbursed by Medicare FFS and Medicaid FFS, the reimbursement amount is as described in section A as appropriate, subject to any applicable benefit limits in the Medicare FFS program and thereafter as described in section B. Form No.: Reimbursement Information (03/1/2013) page 17