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Payment Policies

CommunityCare Claim Payment Policies - Commercial Products

CommunityCare's claim payment policies are designed to assist health care providers when submitting claims, and provide information on how CommunityCare generally adjudicates a claim for the referenced item or service. These policies are subject to change at any time.

Any conflict between a payment policy, the provider's contract with CommunityCare, CommunityCare's Provider Manual, and health plan enrollee's individual or group benefits will be resolved in the following order:

  1. the enrollee's benefits;
  2. the provider's contract;
  3. the Provider Manual; then
  4. the payment policy.

These payment policies are not a guarantee of payment with respect to any particular claim. Claim payment is subject to patient eligibility for coverage on the date of service, the availability of other coverage (e.g., third-party liability or other group or individual coverage), the plan's utilization management and review requirements (e.g., prior authorization; retrospective review for medical necessity; proper coding) and claim editing logic (i.e., to detect improper bundling, unbundling or upcoding).

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