Claim Submission Guidelines for Unlisted Services or Procedures

Some services or procedures may not have specific CPT or HCPCS codes. When submitting claims for these services or procedures, unlisted codes are used until a more specific code is established. In these cases, please refer to the claim submission requirements below. If you have any questions, call (646) 473-7160, and a Provider Relations Representative will assist you.

NON32 To evaluate medical appropriateness, submit the NDC number, drug name and dosage administered. Refer to Section VII of the Summary Plan Description.
NON41 Submit a complete operative report and pertinent information describing the rationale for use of an unlisted surgical code, and the time/effort required. Flag the area that identifies the procedure and provide a comparable CPT code. Refer to Section VII of the Summary Plan Description.
NON42 Submit procedure report describing the rationale for the use of an unlisted medical code, and the time/effort required. Flag the area that identifies the procedure and provide a comparable CPT code. Refer to Section VII of the Summary Plan Description.
NON45 To evaluate medical appropriateness, submit pertinent information describing the nature, extent and need for the DME/medical/surgical supply, a manufacturer invoice specific to the DME supply and the code closest to the actual DME supply.
POL42 Charges for services using an unlisted or temporary code should not be reported when a valid CPT/HCPCS code is available. Resubmit with the appropriate CPT/HCPCS code. Refer to Section VII of the Summary Plan Description.

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