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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 & Medicaid Services, Medicare National Correct Coding Initiative Policy Manual for 
Medicare Services, Chapter I(A). 
 
The rules say that the Physician Fee Schedule Status Indicator A means services paid under other method not 
paid under Outpatient Prospective Payment System (OPPS). Paid by MACs under a fee schedule or payment 
system other than OPPS. You can find this information in the Medicare National Correct Coding Initiative  
 
The rules say that an Outpatient Prospective Payment System (OPPS) payment status indicator is assigned to 
every HCPCS code. The status indicator identifies whether the service described by the HCPCS code is paid 
under the OPPS and if so, whether payment is made separately or packaged. The status indicator may also 
provide additional information about how the code is paid under the OPPS or under another payment system or 
fee schedule. For example, services with status indicator A are paid under a fee schedule or payment system 
other than the OPPS. Services with status indicator N are paid under the OPPS, but their payment is packaged 
into payment for a separately paid service. Services with status indicator T are paid separately under OPPS but 
a multiple procedure payment reduction applies when two or more services with a status indicator of T are 
billed on the same date of service. You can find this rule in the Centers for Medicare & Medicaid Services, 
Internet-Only Manual, Publication 100-04, Medicare Claims Processing Manual, Chapter 4, Section 10.1.1. 
 
The rules say that unconditionally packaged services are services for which separate payment is never made 
because the payment for the service is always packaged into the payment for other services. Unconditionally 
packaged services are identified in the OPPS Addendum B with status indictor of N. See the OPPS Web site at 
http://www.cms.hhs.gov/HospitalOutpatientPPS/ for the most recent Addendum B (HCPCS codes with status 
indicators). In general, the charges for unconditionally packaged services are used to calculate outlier and 
transitional corridor payments (TOP)S payments when they appear on a claim with a service that is separately paid under the OPPS because the packaged service is considered to be part of the package of services for which 
payment is being made through the Ambulatory Payment Classifications (APC) payment for the separately 
paid service. You can find this rule in the Centers for Medicare & Medicaid Services, Internet-Only Manual, 
Publication 100-04, Medicare Claims Processing Manual, Chapter 4, Section 10.4(C1). 
 
The rules say that STV-packaged services are services for which separate payment is made only if there is no 
service with status indicator S, T, or V reported on the same claim. If a claim includes a service that is assigned 
status indicator S, T, or V reported on the same claim as the STV- packaged service, the payment for the STV-
packaged service is packaged into the payment for the service(s) with status indicator S, T, V and no separate 
payment is made for the STV-packaged service. STV-packaged services are assigned status indicator Q1. See 
the OPPS Webpage at http://www.cms.hhs.gov/HospitalOutpatientPPS/ for identification of STV-packaged 
codes. You can find this rule in the Centers for Medicare & Medicaid Services, Internet-Only Manual, 
Publication 100-04, Medicare Claims Processing Manual, Chapter 4, Section 10.4(C2). 
 
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.