The following payment policies apply to medically necessary anesthesia services rendered by in-network or out-of-network providers. The eligibility of benefits for anesthesia services is based on the specific plan provisions or exclusions. Anesthesia services are normally covered when rendered in conjunction with covered surgical procedures.
Description of Service
Anesthesia is the administration of a drug or anesthetic agent by an Anesthesiologist, Certified Registered Nurse Anesthetist, or an Anesthesia Assistant for medical or surgical purposes to obtain muscular relaxation or to induce partial or total loss of sensation to a surgical site or to obtain total loss of consciousness.
Billing and Reimbursement
Anesthesia services can be billed using the following AMA Current Procedural Terminology.
• Anesthesia Services (CPT Codes 00100 – 01999)
• Moderate (Conscious) Sedation (CPT Codes 99143 – 99150)
• Anesthesia add on codes are reported in addition to their primary anesthesia code.
Services rendered by out-of-network providers will be reimbursed using the following relative value calculation.
• Base Units + (Time Units X Conversion Factor) = Regular, Reasonable & Customary Allowance.
Supervision of a CRNA by an anesthesiologist will only be considered for reimbursement if the modifiers of QK or QY are appropriately appended to the billed anesthesia procedure. Services billed by the CRNA must include the appropriate modifier of QX or QZ. When services are billed by both the anesthesiologist and the CRNA, for the same anesthetic service, reimbursement will be split (50%-50%) between the supervising anesthesiologist and the CRNA.
Pekin Life Insurance Company reimburses medically necessary services, provided in the most cost effective setting for the services needed. All policy language for coverage applies.
General benefit information may be verified by faxing a request to 1-309-346-8265. The information will be returned by fax within twenty-four (24) working hours.
An insured may be liable for any of the following:
• Usual & Customary disallowed amounts
• Non-covered services