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Active Health Clinical Policy Guidelines are developed to assist in administering plan benefits and do not constitute medical advice. Treating providers are solely responsible for medical advice and treatment of members. Members should discuss any Clinical Policy Guideline related to their coverage or condition with their treating provider.
While the Clinical Policy Guidelines are developed to assist in administering plan benefits, they do not constitute a description of plan benefits. The Clinical Policy Guidelines express Active Health’s determination of whether certain services or supplies are medically necessary, experimental and investigational, or cosmetic. Active Health has reached these conclusions based upon a review of currently available clinical information (including clinical outcome studies in the peer-reviewed published medical literature, regulatory status of the technology, evidence-based guidelines of public health and health research agencies, evidence-based guidelines and positions of leading national health professional organizations, views of physicians practicing in relevant clinical areas, and other relevant factors).
Active Health makes no representations and accepts no liability with respect to the content of any external information cited or relied upon in the Clinical Policy Guidelines. The discussion, analysis, conclusions and positions reflected in the Clinical Policy Guidelines, including any reference to a specific provider, product, process or service by name, trademark, manufacturer, constitute Active Health’s opinion and are made without any intent to defame. Active Health’s expressly reserves the right to revise these conclusions as clinical information changes, and welcomes further relevant information including correction of any factual error.
Clinical Policy Guidelines include references to standard HIPAA compliant code sets to assist with search functions and to facilitate billing and payment for covered services. New and revised codes are added to the Clinical Policy Guidelines as they are updated. When billing, you must use the most appropriate code as of the effective date of the submission. Unlisted, unspecified and nonspecific codes should be avoided.
Each benefit plan defines which services are covered, which are excluded, and which are subject to dollar caps or other limits. Members and their providers will need to consult the member’s benefit plan to determine if there are any exclusions or other benefit limitations applicable to this service or supply. The conclusion that a particular service or supply is medically necessary does not constitute a representation or warranty that this service or supply is covered (i.e., will be paid for by a member’s benefit plan) for a particular member. The member’s benefit plan determines coverage. Some plans exclude coverage for services or supplies that Active Health considers medically necessary. If there is a discrepancy between a Clinical Policy Guideline and a member’s plan of benefits, the benefits plan will govern.
Please note also that Clinical Policy Guidelines are regularly updated and are therefore subject to change.
Since Clinical Policy Guidelines can be highly technical and are designed to be used by our professional staff in making clinical determinations in connection with coverage decisions, members should review these Bulletins with their providers so they may fully understand our policies.
While Clinical Policy Guidelines define Active Health’s clinical policy, medical necessity determinations in connection with coverage decisions are made on a case by case basis. In the event that a member disagrees with a coverage determination, Active Health provides its members with the right to appeal the decision. In addition, a member may have an opportunity for an independent external review of coverage denials based on medical necessity or regarding the experimental and investigational status when the service or supply in question for which the member is financially responsible is $500 or greater. However, applicable state mandates will take precedence with respect to fully insured plans and self-funded non-ERISA (e.g., government, school boards, church) plans.
The five character codes included in the Active Health Clinical Policy Guidelines are obtained from Current Procedural Terminology (CPT®), copyright 2015 by the American Medical Association (AMA). CPT is developed by the AMA as a listing of descriptive terms and five character identifying codes and modifiers for reporting medical services and procedures performed by physicians.
The responsibility for the content of Active Health Clinical Policy Guidelines is with Active Health and no endorsement by the AMA is intended or should be implied. The AMA disclaims responsibility for any consequences or liability attributable or related to any use, nonuse or interpretation of information contained in Active Health Clinical Policy Guidelines. No fee schedules, basic unit values, relative value guides, conversion factors or scales are included in any part of CPT. Any use of CPT outside of Aetna Clinical Policy Bulletins (CPBs) should refer to the most current Current Procedural Terminology which contains the complete and most current listing of CPT codes and descriptive terms. Applicable FARS/DFARS apply.