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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 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).

The rules say that A/B MACs (B) may not pay for the technical component (TC) of radiology services 
furnished to hospital patients. Payment for physicians' radiological services to the hospital, 
e.g., administrative or supervisory services, and for provider services needed to produce the 
radiology service, is made by the A/B MAC (A) to the hospital as a provider service. A/B MACs (A) 
include the TC of radiology services for hospital inpatients, except Critical Access Hospitals 
(CAHs), in the prospective payment system (PPS) payment to hospitals. Hospital bundling rules 
exclude payment to suppliers of the TC of a radiology service for beneficiaries in a hospital 
inpatient stay. The TC of radiology and other diagnostic services furnished to hospital outpatients 
are paid under the Outpatient Prospective Payment System (OPPS) to the hospital. You can find this 
information in the Centers for Medicare and Medicaid Services (CMS), Internet-Only Manual 
Publication 100-04, Medicare Claims Processing Manual Chapter 13, Section 20.2.1.

The rules also say that the Correct Coding Initiative was developed to promote correct coding and 
to control improper coding leading to inappropriate payment in Part B claims. The Coding Policy 
Manual also explains what is referred to as Column One/Column Two Correct Coding and Mutually 
Exclusive Edits. These are code pairs that should not be reported together. Medicare Administrative 
Contractors (MACs) subject all line items for the same beneficiary, same National Provider 
Identifier (NPI), and same date of service to National Correct Coding Initiative (NCCI) edits. The 
National Correct Coding Initiative (NCCI) File Formats continue to include a Correct Coding 
Modifier Indicator (CCMI) for the Column One / Column Two Correct Coding edit file. This indicator 
determines whether an NCCI Procedure to Procedure (PTP)-associated modifier causes the
code pair to bypass the edit.


The rules say that services with a Status Indicator of P are bundled/excluded codes. There are no 
relative value units and no payment amounts for these services. No payment is made for them under the fee 
schedule.

Medicare rules say that services with a Professional/Technical Indicator of 5 are "Incident to 
Codes". This indicator identifies codes that describe services covered incident to a physicians 
service when they are provided by auxiliary personnel employed by the physician and working under 
his or her direct supervision. Payment may not be made by carriers for these services when they are 
provided to hospital inpatients or patients in a hospital outpatient department. Modifiers 26 and 
TC cannot be used with these codes.

You can find these rules in the Centers for Medicare and Medicaid Services, Internet Only Manual, 
Publication 100-04, Medicare Claims Processing Manual, Chapter 23, Sections 20.9, 30.2.2, and 50.6.

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.