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Claims Payment Policy __________________________________________________________
Hometown Health ’ s medical claims payment policy incorporates clinical logic based on clinical practice and reimbursement standards . Please note that Hometown Health ’ s payment policy is subject to each payer ’ s payment policies ( TPA / self-funded and lease networks ), and any or all payment policy edits are subject to change .
Hometown Health reimburses providers according to its standard payment policies . In developing its standard payment policies , we consider current healthcare trends and advances , as well as information from a variety of different sources , including but not limited to : provider questions and comments ; guidelines from CMS ; AMA guidelines ; CPT Assistant ; Correct Coding Initiative ; Change Healthcare formerly TC3 and , specialty medical societies . However , Hometown Health ’ s standard payment policies may differ from policies adopted , endorsed , or recommended by any or all of those sources .
Hometown Health uses an automated code-auditing tool in its claims processing system . This code-auditing tool incorporates edits based on Hometown Health ’ s standard payment policies . If a claim submitted for payment is not in accordance with Hometown Health ’ s standard payment policies , we may deny or pend payment on the claim completely or partially .
In the event of a conflict between Hometown Health ’ s standard payment policies and an automated edit , Hometown Health ’ s standard payment policies will control . Additionally , all payment decisions are subject to all terms and conditions of the applicable benefit plan , including specific exclusions and limitations , and to all applicable state and / or federal laws .
If your claim or portion of a claim is denied for any reason or you want to understand the actual payment edits and reimbursement , you may appeal the decision by following the procedures as explained in this Provider Manual .
Reviewing a claim
When our system reviews a claim , it applies edits that may result in non-payment of the entire claim or service lines within the claim . The edits consist of logic that enables the claim review system to select claims containing certain values or combinations of procedure codes .
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