Payment Policies

Introduction to the Payment Policy Manual

By accessing and reviewing these payment policies, providers acknowledge and agree that:

• Reference Tool: These policies are intended as a reference to assist providers in submitting accurate claims and outline the basis for reimbursement of covered services. They apply to services rendered by all providers billing HMSA.
• Subject to Change: The policies are subject to changes in industry coding rules and guidelines, such as those established by CPT®, HCPCS, ICD, and other nationally recognized standards. At times, coding changes may take effect before this manual is formally updated.
• Regulatory and Contractual Revisions: Policies may be revised based on state or federal requirements, regulatory guidance, or modifications to provider agreements.

Limitations:

• These payment policies do not constitute billing or coding advice.
• They do not guarantee payment or determine benefit coverage.
• They do not supersede member benefit documents, provider contracts, medical policies, or claim editing rules.
• They do not dictate how other Blue Cross and/or Blue Shield Plans set allowances for care rendered by their providers.
• They do not constitute medical advice or clinical guidance.

This manual should be used in conjunction with applicable benefit documents, provider agreements, medical policies, and claim editing rules to ensure compliance and proper claims submission.

Provider Payment Policies

These payment policies are not comprehensive of all payment guidelines and policies outlined on the PRC. Providers are responsible for reviewing all applicable policies, guidelines, and resources when submitting claims.

• Advanced Primary Care Management Services – effective 03/01/2026 [PDF]
• Payment Policies Enhanced Code Editing – 11/01/2025 [PDF]

Archived Payment Policies

Revision History