What ClaimDoc covers, payer by payer.
Listing a payer isn't the same as knowing its rules. This page says, for each payer and each specialty, what has been tested, what policy ClaimDoc holds word for word, and what it can only ask the payer for.
How to read a payer's row
- Tested end to end
- Policy text indexed
- Policy sources on file
- General rules
Plans differ inside one payer: a Medicare Advantage plan, a regional Blue plan, a Medicaid managed care plan and a commercial plan from the same company can all follow different rules. Where ClaimDoc doesn't hold a plan's policy it says so in the letter and asks for the criteria used, rather than guessing.
The directory: 166 payers
166 payers and plan families, including all 51 state Medicaid programs, the Medicare contractors, the Blue Cross Blue Shield plans, regional plans, employer plan administrators and the utilization managers that deny claims on a plan's behalf. Payer names are text, not logos; ClaimDoc isn't affiliated with or endorsed by any of them.
Aetna
Tested end to end
Cigna Healthcare
Tested end to end
Elevance Health (Anthem)
Tested end to end
Humana
Tested end to end
Original Medicare (Part A outpatient and Part B)
Tested end to end
UnitedHealthcare
Tested end to end
Aetna Medicare Advantage
Policy sources on file
Alignment Healthcare
Policy sources on file
CGS Administrators (Jurisdiction 15)
Policy sources on file
Cigna Medicare Advantage
Policy sources on file
Clover Health
Policy sources on file
Devoted Health
Policy sources on file
First Coast Service Options (Jurisdiction N)
Policy sources on file
Noridian Healthcare Solutions (Jurisdiction E)
Policy sources on file
Noridian Healthcare Solutions (Jurisdiction F)
Policy sources on file
Novitas Solutions (Jurisdiction H)
Policy sources on file
Novitas Solutions (Jurisdiction L)
Policy sources on file
Optum Behavioral Health
Policy sources on file
Palmetto GBA (Jurisdiction J)
Policy sources on file
Palmetto GBA (Jurisdiction M)
Policy sources on file
SCAN Health Plan
Policy sources on file
Wellpoint Federal, formerly National Government Services (Jurisdiction 6)
Policy sources on file
Wellpoint Federal, formerly National Government Services (Jurisdiction K)
Policy sources on file
WPS Government Health Administrators (Jurisdiction 5)
Policy sources on file
WPS Government Health Administrators (Jurisdiction 8)
Policy sources on file
Aetna Better Health
General rules
Alabama Medicaid
General rules
Alaska Medicaid
General rules
Allied Benefit Systems
General rules
AmeriHealth Caritas
General rules
Specialties: what has passed testing
A specialty is “tested” only when a full synthetic appeal for it ran through the real system from upload to a finished packet and passed every check: the right route, every factual sentence traced to a page of the record or a stored policy, and independent verification. The others have their requirements and sources on file and are in validation.
| Specialty | Group | Status | What ran |
|---|---|---|---|
| Physical therapy | Rehabilitation | Tested end to end | Medical necessity appeal built on Medicare's form; 25 of 25 sentences sourced; KX threshold redetermination built; 30 of 30 sentences sourced |
| Occupational therapy | Rehabilitation | Tested end to end | Continued hand therapy after a wrist fracture appealed on Aetna's form; 14 of 14 sentences sourced |
| Speech-language pathology | Rehabilitation | Tested end to end | A child's language-disorder therapy appealed from test scores and progress probes; 13 of 13 sentences sourced |
| Chiropractic | Rehabilitation | Tested end to end | A maintenance-therapy denial answered point by point against Medicare's stored chiropractic rules; the contractor's LCD named; 19 of 19 sentences sourced |
| Psychiatry | Behavioral health | In validation | Requirements and sources on file; no end-to-end run has passed yet. |
| Psychology | Behavioral health | In validation | Requirements and sources on file; no end-to-end run has passed yet. |
| Counseling and mental health therapy | Behavioral health | Tested end to end | Psychotherapy appealed on Cigna's form, with progress shown by symptom scores; 19 of 19 sentences sourced |
| Primary care | Primary care | In validation | Requirements and sources on file; no end-to-end run has passed yet. |
| Dermatology | Medical specialties | Tested end to end | A cyst excision denied as cosmetic appealed from symptoms, prior treatment and pathology; 14 of 14 sentences sourced |
| Cardiology | Medical specialties | In validation | Requirements and sources on file; no end-to-end run has passed yet. |
| Orthopedics | Medical specialties | In validation | Requirements and sources on file; no end-to-end run has passed yet. |
| Pain management | Medical specialties | Tested end to end | A repeat epidural injection appealed on the documented relief from the last; the contractor's LCD named; 18 of 18 sentences sourced |
| Neurology | Medical specialties | In validation | Requirements and sources on file; no end-to-end run has passed yet. |
| Gastroenterology | Medical specialties | In validation | Requirements and sources on file; no end-to-end run has passed yet. |
| Podiatry | Medical specialties | In validation | Requirements and sources on file; no end-to-end run has passed yet. |
| Urology | Medical specialties | In validation | Requirements and sources on file; no end-to-end run has passed yet. |
| Ophthalmology | Medical specialties | In validation | Requirements and sources on file; no end-to-end run has passed yet. |
| Other outpatient physician practice | Medical specialties | In validation | Requirements and sources on file; no end-to-end run has passed yet. |
The runs behind “tested”
| Payer | Specialty | What happened | Run |
|---|---|---|---|
| Original Medicare (Part A outpatient and Part B) | Physical therapy | Medical necessity appeal built on Medicare's form; 25 of 25 sentences sourced | 2026-11-12 |
| Original Medicare (Part A outpatient and Part B) | Physical therapy | KX threshold redetermination built; 30 of 30 sentences sourced | 2026-11-12 |
| Original Medicare (Part A outpatient and Part B) | Physical therapy | Stopped and named the unsigned plan of care | 2026-11-12 |
| Humana | Physical therapy | Medicare Advantage appeal with signed waiver of liability; 26 of 26 sourced | 2026-11-12 |
| Aetna | Physical therapy | Appeal against Aetna's own policy from a scanned evaluation; 33 of 33 sourced | 2026-11-12 |
| Aetna | Physical therapy | Planted instructions in a note never reached the letter; 21 of 21 sourced | 2026-11-12 |
| Cigna Healthcare | Physical therapy | Prior authorization appeal on Cigna's form; 12 of 12 sourced | 2026-11-12 |
| UnitedHealthcare | Physical therapy | Routed to a corrected claim instead of an appeal | 2026-11-12 |
| Aetna | Occupational therapy | Continued hand therapy after a wrist fracture appealed on Aetna's form; 14 of 14 sentences sourced | 2026-11-12 |
| UnitedHealthcare | Speech-language pathology | A child's language-disorder therapy appealed from test scores and progress probes; 13 of 13 sentences sourced | 2026-11-12 |
| Original Medicare (Part A outpatient and Part B) | Chiropractic | A maintenance-therapy denial answered point by point against Medicare's stored chiropractic rules; the contractor's LCD named; 19 of 19 sentences sourced | 2026-11-12 |
| Cigna Healthcare | Counseling and mental health therapy | Psychotherapy appealed on Cigna's form, with progress shown by symptom scores; 19 of 19 sentences sourced | 2026-11-12 |
| Original Medicare (Part A outpatient and Part B) | Pain management | A repeat epidural injection appealed on the documented relief from the last; the contractor's LCD named; 18 of 18 sentences sourced | 2026-11-12 |
| Elevance Health (Anthem) | Dermatology | A cyst excision denied as cosmetic appealed from symptoms, prior treatment and pathology; 14 of 14 sentences sourced | 2026-11-12 |
The policy library
17 sources are stored word for word, each with its link, its date and the exact passages the letter can quote. 330 Medicare coverage documents (local coverage determinations, billing articles and national determinations) are listed from CMS's Medicare Coverage Database, last refreshed 2026-11-12; the letter names the one for your contractor when a denial rests on it.
| Source | Kind | Link |
|---|---|---|
| Medicare Benefit Policy Manual, Chapter 15, §220–230 (Outpatient therapy) (Pub. 100-02, Ch. 15 §220–230) | Stored word for word | Official source |
| MLN905365: Complying with Outpatient Rehabilitation Therapy Documentation Requirements (MLN905365) | Stored word for word | Official source |
| CMS Therapy Services: KX modifier threshold | Stored word for word | Official source |
| Jimmo v. Sebelius settlement: skilled maintenance therapy | Stored word for word | Official source |
| Medicare Claims Processing Manual, Chapter 5 (Part B outpatient rehabilitation), §10–20 (Pub. 100-04, Ch. 5) | Stored word for word | Official source |
| Medicare Claims Processing Manual, Chapter 29 (Appeals), redetermination sections (Pub. 100-04, Ch. 29) | Stored word for word | Official source |
| Medicare Claims Processing Manual, Chapter 34 (Reopening and revision) (Pub. 100-04, Ch. 34) | Stored word for word | Official source |
| CMS: First level of appeal, redetermination by a Medicare contractor | Stored word for word | Official source |
| 42 CFR 422.582: Request for a standard reconsideration (Medicare Advantage) (42 CFR 422.582) | Stored word for word | Official source |
| 29 CFR 2560.503-1: ERISA claims procedure (29 CFR 2560.503-1) | Stored word for word | Official source |
| Aetna Clinical Policy Bulletin 0325: Physical Therapy (CPB 0325) | Stored word for word | Official source |
| Cigna Medical Coverage Policy CPG 135: Physical Therapy (CPG 135) | Stored word for word | Official source |
| Cigna Healthcare: Appeals and disputes policy and procedures (health care providers) | Stored word for word | Official source |
| Medicare Benefit Policy Manual, Chapter 15, §240 (Chiropractic services) (Pub. 100-02, Ch. 15 §240) | Stored word for word | Official source |
| Medicare Benefit Policy Manual, Chapter 15, §160 (Clinical psychologist services) (Pub. 100-02, Ch. 15 §160) | Stored word for word | Official source |
| Medicare Benefit Policy Manual, Chapter 15, §170 (Clinical social worker services) (Pub. 100-02, Ch. 15 §170) | Stored word for word | Official source |
| Medicare Benefit Policy Manual, Chapter 15, §290 (Foot care) (Pub. 100-02, Ch. 15 §290) | Stored word for word | Official source |
| Aetna Clinical Policy Bulletin 0107: Chiropractic Services (CPB 0107) | Located, linked | Official source |
| Aetna Clinical Policy Bulletin 0250: Occupational Therapy (CPB 0250) | Located, linked | Official source |
| Aetna Clinical Policy Bulletin 0243: Speech Therapy (CPB 0243) | Located, linked | Official source |
| Aetna Clinical Policy Bulletin 0158: Neuropsychological and Psychological Testing (CPB 0158) | Located, linked | Official source |
| Aetna Clinical Policy Bulletin 0554: Applied Behavior Analysis (CPB 0554) | Located, linked | Official source |
| Cigna Medical Coverage Policy CPG 278: Chiropractic Care (CPG 278) | Located, linked | Official source |
| Cigna: Appeals and disputes (provider payment appeals, records and time limits) | Located, linked | Official source |
| UnitedHealthcare Commercial Medical Policy: Manipulative Therapy | Located, linked | Official source |
| UnitedHealthcare Commercial Reimbursement Policy: Physical Medicine, Rehabilitation and Speech Therapy | Located, linked | Official source |
| Humana: Medical record review requirements | Located, linked | Official source |
| Optum Level of Care Guidelines (behavioral health) | Located, linked | Official source |
Keeping it current
- Each source keeps its link, its date and a fingerprint of its text. A source that has changed is flagged in ClaimDoc's library and isn't quoted until it has been read again.
- Medicare coverage listings are regenerated from CMS's own database, not edited by hand.
- Nothing is listed without an official source. Where we couldn't confirm a page, the row says so.
Don't see your payer or specialty? Tell us, or read how records are protected.