Effective Date: Nov. 10, 2026

Health Plans Affected: US Family Health Plan (USFHP) 

Type of Change: Policy

Explanation of Change:

Johns Hopkins Health Plans has released its notification of the new and updated reimbursement policies, as listed below:

Reminders About Johns Hopkins Health Plans Reimbursement Policies
Unless otherwise specified, Johns Hopkins Health Plans reimbursement policy guidance applies to all items and services reported on CMS-1500/837P and UB-04/837I claim forms, when submitted by a health care professional, provider, supplier or facility, regardless of network participation (in-network or out-of-network) status.

Provider: Any individual or entity that is licensed, certified or otherwise authorized under applicable state and federal laws to furnish, bill for, or receive reimbursement for covered health care services, items or supplies.

Providers are required to use industry‑standard, compliant coding on all claim submissions and to review our Reimbursement Policies to identify any instances where billing requirements may differ.

USFHP Ancillary and Adjunct Services (RPC.053) – New Policy

• In accordance with TRICARE^® guidance, when a primary procedure is denied, any items or services that are integral, incidental, related to, or dependent upon the denied primary procedure will also be denied, whether furnished by the same or another provider, supplier or facility.
• Providers may submit documentation which clearly supports a separately identifiable item or service as medically necessary, independently covered and is not inclusive of or dependent upon the denied primary procedure to be reviewed for payment eligibility.

Non-Reimbursable Codes (RPC.026) – Updated for USFHP only

• New appendix added to policy containing updated language, tables, references and billing and coding guidance applicable to USFHP only, which may affect reimbursement for certain services, in alignment with regulatory requirements and organizational directives.
• Facilities are required to report covered and non-covered items/services on separate claim lines, including all line-item details (e.g., HCPCS, rev code, charges, units, value codes, occurrence codes). Claim lines with non-covered charges must also include the disallowed amount.
• Inpatient claims must report both covered and non-covered days on separate lines, including the associated charges.

Note: This guidance does not permit providers to separately report or unbundle services and supplies already included in another billed service or otherwise not separately reimbursable, whether inpatient or outpatient. All claims are subject to review for correct coding, payment and coverage determination.

Discontinued Procedures (RPC.019); Age, Gender/Sex Based Codes (RPC.044) - Updated
Policy guidelines have been updated to incorporate multiple billing and coding revisions that may affect reimbursement for certain services. These updates ensure continued alignment with regulatory requirements, industry standards and organizational directives. Changes include, but are not limited to:

• Policy template update
  
• Enhanced policy language
  
• Updates to billing and coding guidance in alignment with authoritative rules and regulations, applicable to the health plan
  
• Updated lists, tables, references and definitions within the policy
  
• Removal of deleted codes and outdated guidance

REFERENCES

• CMS Regulations & Guidance
  
• COMAR- Maryland Department of Health (MDH)
  
• CPT^® Copyright American Medical Association
  
• JHHP Reimbursement Policies
  
• MDH Provider Information Site
  
• NCCI for Medicare | CMS
  
• NCCI for Medicaid | CMS
  
• Novitas Solutions- Medicare Administrative Contractor
  
• TRICARE Manuals