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The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101.
The rules say that modifiers are used to identify therapy services whether or not financial limitations are in effect. Providers/suppliers must continue to report one of these modifiers for any therapy code on the list of applicable therapy codes. These modifiers do not allow a provider to deliver services that they are not qualified and recognized by Medicare to perform. The claim must include one of the following modifiers to distinguish the discipline of the plan of care under which the service is delivered: GN Services delivered under an outpatient speech-language pathology plan of care; GO Services delivered under an outpatient occupational therapy plan of care; or, GP Services delivered under an outpatient physical therapy plan of care. This is applicable to all claims from physicians, nonphysician practitioners (NPPs), PTPPs, OTPPs, SLPPs, CORFs, OPTs, hospitals, SNFs, and any others billing for physical therapy, speech-language pathology or occupational therapy services as noted on the applicable code list in 20 of this chapter. Modifiers GN, GO, and GP refer only to services provided under plans of care for physical therapy, occupational therapy and speech-language pathology services. They should never be used with codes that are not on the list of applicable therapy services. For example, respiratory therapy services, or nutrition therapy services shall not be represented by therapy codes which require GN, GO, and GP modifiers. Contractors edit institutional claims to ensure the following: that a GN, GO or GP modifier is present for all lines reporting revenue codes 042X, 043X, or 044X, that no more than one GN, GO or GP modifier is reported on the same service line, that revenue codes and modifiers are reported only in the following combinations: o Revenue code 42x (physical therapy) lines may only contain modifier GP o Revenue code 43x (occupational therapy) lines may only contain modifier GO. Revenue code 44x (speech-language pathology) lines may only contain modifier GN. - that discipline-specific evaluation and re-evaluation HCPCS codes are always reported with the modifier for the associated discipline (e.g. modifier GP with a HCPCS code for a physical therapy evaluation). Contractors return to the provider institutional claims that do not meet one or more of these conditions. You can find this rule in the Medicare Claims Processing Manual Chapter 5, Section 20.1 - Discipline Specific Outpatient Rehabilitation Modifiers.
The rules say that providers/suppliers must report services correctly. Procedures should be reported with the Current Procedural Terminology (CPT) code that describes the services performed. You can find this rule in the Centers for Medicare and Medicaid Services, Medicare National Correct Coding Initiative Policy Manual for Medicare Services, Chapter I(A).
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.
The Plan contract says that the Plan covers items and services in accordance with Medicare rules.