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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 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 healthcare common 
procedure code system (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. Services with status indicator N are paid under the 
OPPS, but their payment is packaged into payment for a separately paid service. You can find this rule in the 
Centers for Medicare and Medicaid Services, Internet Only Manual, Publication 100-04, Medicare Claims 
Processing Manual, Chapter 4, Section 10.1.1. 
 
The rules say that composite ambulatory payment classifications (APCs) provide a single payment for a 
comprehensive diagnostic and/or treatment service that is defined, for purposes of the APC, as a service 
typically reported with multiple HCPCS codes. When HCPCS codes that meet the criteria for payment of the 
composite APC are billed on the same date of service, CMS makes a single payment for all of the codes as a 
whole, rather than paying individually for each code. A service that is assigned to a composite APC is a major 
component of a single episode of care. The hospital receives one payment through a composite APC for 
multiple major separately identifiable services. Services mapped to composite APCs are assigned status 
indicator Q3. You can find this rule in the Centers for Medicare and Medicaid Services, Internet Only Manual, 
Publication 100-04, Medicare Claims Processing Manual, Chapter 4, Sections 10.2.1 and 10.4.C(4). 
 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. You 
can find this rule in the Centers for Medicare and Medicaid Services, Internet Only Manual, Publication 100-
04, Medicare Claims Processing Manual, Chapter 4, Section 10.4.C(2). 
 
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.