Provider Bulletin: Special Policy Edition



In this bulletin, we want to share important policy updates, changes for prior approvals and a switch to email to communicate with you more effectively. 

Notification of New Policies Effective 10/15/2025 



Self-administered medications not covered by the medical benefit 

Community Health Options does not cover medications that Members can take themselves without direct supervision by a qualified provider or licensed/certified medical professional. During a hospital or outpatient visit, these are considered self-administered medications and not covered under our Members’ medical benefits.

Non-Covered:

Please refer to the Self-Administered Medications list for applicable HCPCS and NDC codes for medications Community Health Options has determined to be “self-administered” based upon clinical coverage rationale.

Community Health Options Treatment Room Reimbursement Policy 

Treatment room services are outpatient services on hospital premises that require using a bed, and periodic monitoring for a short time to carry out certain procedures, not otherwise billable in a specialized suite.

Separate treatment room services are non-covered when billed with:

•      Emergency room visit

•      Inpatient stay

•      Laboratory or radiology services (sole purpose)

•      Outpatient minor surgical or medical procedure

•      Outpatient observation stay

•      Urgent care visit

Using a treatment room is an expected part of a minor procedure and replaces the charge for the operating room and recovery room, because patients can also recover where they’ve already been treated. Operating rooms, meanwhile, are procedure rooms within a sterile corridor and are used for open or major surgical procedures usually involving general anesthesia.

Learn more here: Treatment Room Billing Guidelines

Use the correct modifiers for durable medical equipment to be properly reimbursed 

Community Health Options requires all durable medical equipment capped rental claims to be billed using the appropriate rental modifier, followed by the applicable rental month modifier to be considered for reimbursement.

See the full policy here: DME Capped Rental

Community Health Options adheres to the billing/coding guidelines defined by American Medical Association (AMA) and Centers for Medicare and Medicaid Services (CMS) for appropriate use of modifiers that may be appended to HCPCS/CPT codes to provide additional information about the services rendered.

Durable Medical Equipment (DME) Rental Modifiers:

Capped rental: A special payment structure for certain types of durable medical equipment (DME) that helps spread out costs over time and ensures the beneficiary eventually owns the item if it’s still medically necessary.

Update: Previously published policies to be implemented in September

The following policies we’ve already shared with you will be effective on Sept. 15.

• Distinct modifier: Community Health Options will be reviewing claims billed with medical records for support in the usage of distinct modifiers, in accordance with the National Correct Coding Initiatives (NCCI), CPT/HCPCS coding guidelines, and our Modifier Reference Guide. For example: When a provider bills 45380 and 45385 on the same day, the provider may use modifier 59 or XS when medical records support performing on separate lesions. Otherwise, we will reimburse the more extensive procedure 45385 with no additional reimbursement for the lesser 45380.

• Drug administration on professional claims: Community Health Options Routine Policy, initially published June 2019, states the “administration of” services are not separately payable. For example: IV infusion is not separately payable when billing the IV drug by the same provider on the same date of service. Community Health Options considers reimbursement for drug charges, regardless of the method of administration. This will now include professional claims (CMS-1500).

•  National drug code: Community Health Options (NDC) – National Drug Code Billing Requirements Policy published June 2022 states:

Community Health Options follows the industry standard, in alignment with CMS requirement, to require the following information, in designated claim form fields, for drug-related medical claims:

• Appropriate Healthcare Common Procedure Coding System (HCPCS) or Current Procedural Terminology (CPT®) codes
• Units of HCPCS or CPT codes
• Valid 11-digit NDC, including the N4 qualifier
• NDC unit of measurement (F2, GR, ML, or UN)
• NDC units administered/dispensed (must be greater than 0)

Drug-related medical claims are outpatient services billed under:

• CMS-1450 (UB-04, 837i) for hospitals and facilities
• CMS-1500 (837p) for providers

No Prior Approval required for services offered effective, July 1, 2025

Home Health / Hospice 

G0151 - G0162

G0299 - G0300 

G0493 - G0496 

Q5001 - Q5002

Q5009 

Radiation Treatment Codes

77261 - 77263 

77280 - 77293 

77295 - 77370 

77371 - 77373 

77385 - 77387 

77401 - 77407 

77412 - 77425 

77427 - 77470 

77520 - 77525 

77761 - 77790 

78800 - 78832 

S codes for fluid/IV hydration/tube feeds: S9208 – S9377

Cardiac Monitors (Holter): 93245 – 93248

EGD’s: 43210 – 43270

Vaginal Hysterectomy: 58260 – 58294

Laparoscopic Hysterectomy: 58541 – 58544

Laparoscopic Cholecystectomy: 47562 – 47563

Laparoscopic Appendectomy: 44970

We are moving to email for itemized bills, medical records and insurer settlement reports 

To streamline how we share information with you, and to reduce the amount of paper we’re using, we will be using email to exchange Itemized Bills (IBs) and medical records, along with receiving Insurer Settlement Reports (ISRs). 

Effective immediately:

• Itemized Bills (IBs), should be submitted via email to:

  itemizedbill@healthoptions.org We will send the corresponding Insurer Settlement Report (ISR) to the same email address you use to send your itemized bill.

•  Medical Records should be submitted via email to:

medicalrecords@healthoptions.org

Please note: Beginning Sept. 15. we will no longer mail ISRs. If you need to request an ISR after this date, please call our Provider Services team at: (855) 624-6463.

We appreciate your cooperation as we move toward a more efficient and environmentally friendly process.

Resources  

Urgent Care Provider Sheet 

Company Profile 

Availity Portal 

Community Health Options Website Provider Resources  

Community Health Options’ Provider Network 

If you have any questions

please email:

provider@healthoptions.org