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Premera Blue Cross follows industry standard recommendations from sources such as the Centers for Medicare and Medicaid Services (CMS), Current Procedural Terminology (CPT), the American Medical Association (AMA), and/or other professional organizations and societies. National Correct Coding Initiative (NCCI) editing is followed when applicable. Any exceptions are documented as Payment Policies. Coverage of any service is determined by a member’s eligibility, benefit limits for the service or services rendered and the application of the Plan’s Medical Policy. Final payment is subject to the application of claims adjudication edits common to the industry and the Plan’s facility services claims coding policies. Reimbursement is restricted to the provider's scope of practice as well as the fee schedule applicable to that provider.
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