Information for Providers

Aspirus Health Plan Payment Policies Disclaimer

Aspirus Health Plan payment policy website contains payment policies that assist in administering payment for Aspirus Health Plan benefits under Aspirus Health Plan’s benefit plans. Payment Policies are intended to serve only as a general reference resource regarding Aspirus Health Plan’s administration of health benefits and are not intended to address all issues related to payment for health care services provided to Aspirus Health Plan members.

Payment Policies are provided for informational purposes and do not constitute coding or compliance advice. Providers are responsible for submission of accurate and compliant claims.

Aspirus Health Plan reserves the right at its sole discretion to modify its policies and guidelines as necessary, and to administer payments in a manner other than as described by Aspirus Health Plan Payment Policies when necessitated by operational or regulatory considerations.

Payment Policies are published online and available to members, providers and the general public. To view Aspirus Health Plan payment policies select “I Agree” at the bottom of the page.

In addition to Payment Policies, Aspirus Health Plan also uses tools developed by third parties, such as the Current Procedural Terminology (CPT®), InterQual guidelines, Centers for Medicare and Medicaid Services (CMS) and other coding guidelines to assist in administering health benefits. References to CPT® or other sources in Aspirus Health Plan Payment Policies are for definitional purposes only and do not imply any right to payment. Other Aspirus Health Plan Policies and Guidelines may also apply.

How Payment Policies Are Developed

Aspirus Health Plan’s payment policies are based on available regulatory and coding guidance and, where applicable, community standards. Payment Policies are revised and updated annually; however, Policies may be reviewed prior to their scheduled review date if new guidance or standards that would alter the Policy criteria become available sooner.

How Payment Policies Are Used

When making payment determinations, Aspirus Health Plan staff will identify member eligibility, federal and state legislation or regulatory guidance regarding claims submission, Aspirus Health Plan provider participation agreement contract terms and the member-specific Evidence of Coverage (EOC) or other benefit documents. In the event of a conflict, the enrollee’s specific benefit document and federal and state legislation and regulatory guidance supersede the payment policies. In the absence of regulatory guidance that governs payment for the service, procedure or treatment, or when the member’s EOC document is silent or not specific, payment policies help to clarify how Aspirus Health Plan will pay for certain health care services.

CPT® is a registered trademark of the American Medical Association

If you understand and agree with the terms and conditions stated above, please click “I Agree.”