This is the Schedule of procedures and fees for providers recognised by AXA PPP healthcare. It includes codes for procedures for which our policies provide benefit and is based on work undertaken by the Clinical Coding and Schedule Development group (CCSD). It also details billing principles which apply to invoices for private medical services provided to our members.

Reimbursement Status

In all instances specialists or clinical and complementary practitioners must work within their scope of practice and in line with their professional codes of conduct. Any new procedures that are not routinely undertaken within their routine practice must be considered and agreed by AXA PPP healthcare in advance and in conjunction with the clinical governance committees at the treating facility.

This document sets out what AXA PPP healthcare would expect specialist and practitioners to charge for the services they provide to patients. We will pay eligible fees in full when a specialist or practitioner charges up to the level shown within this document for treatment that they have provided; no payments will be made for supervision of services provided by others. All services claimed for must be listed in the Schedule of Procedures and Fees.

We have identified certain specialists and practitioners whose fees exceed this limit and these specialists’ and practitioners’ charges will always be limited to the level shown in the Schedule of Procedures and Fees for Fee Limited Specialists and any excess charge over this amount will not be reimbursed.

Billing Principles

The main principles which all providers must adhere to as a condition of recognition are as follows:

Procedure Code Query
If the operator is uncertain how to code for a specific procedure then they can ask us to advise what code they should use. To determine what the appropriate representative code is we will require the following information, a copy of the clinic letter and/or a justification letter detailing what is planned to take place during the treatment so that we can identify the most appropriate code for the planned treatment, this can be sent to us by using the following link

Procedure Fees
The operator fee for a procedure includes all component parts of that procedure including preoperative assessment, the procedure itself and all routine aftercare including out-patient consultation for at least the first ten days. All our fees are inclusive of VAT.

We do not accept separate charges for giving sub-cutaneous, intramuscular or intravenous injections (or vaccinations where eligible) as on their own these are not deemed to be separate surgical procedures and any charge for giving injections is covered by the standard consultation charge.

Invoices must be coded using the industry standard CCSD codes as listed in this Schedule. The only item which should appear on an invoice is the (usually single ) CCSD code for the procedure being performed. This code should only be used for the use set out in the standard description. If a code states ‘as sole procedure’ in its narrative it should not be performed in addition to another procedure. If any procedure is undertaken which is not coded, specialists should contact the specialist fees team with a detailed letter outlining what is being done and a breakdown of the proposed cost so that we can identify the most appropriate code to be used or the most appropriate level of reimbursement for the planned treatment, this can be sent to us by using the following link Diagnostic tests should be itemised and accurately coded as per the CCSD coding and narratives, these can be obtained from the CCSD website

The component parts of single procedures or services must not be itemised out and billed as if they were separate or additional services. As a guide, there is no clinical intervention which should routinely need more than one code.
We will not reimburse additional charges for component parts of single procedures and will withdraw recognition from providers who persistently unbundle charges. Unbundling includes:

  • Charging for two procedures where one is part and parcel of the other or is so frequently performed that it is in effect part and parcel.
  • Charging for in-patient care or ITU care where this is simply routine post-operative care.
  • Charging for pre-operative assessment or post-operative analgesia including nerve blocks.
  • Using procedure combinations whose primary purpose is to increase reimbursement. An example of this would be charging for wound infiltration with local anaesthesia.
  • Charging for anaesthetic when anaesthetic services have also been provided by an anaesthetist.

Multiple Procedures
Different insurance companies have different rules about fees for multiple procedures. Where two procedures are performed at the same time we will pay full benefit for the highest rated procedure and 50% of the fee for the second highest rated procedure. Only in the most exceptional circumstances and on a case-by-case basis discussed prior to any treatment taking place will further procedures be considered for additional reimbursement. Please contact the specialist fees team via the following link & include copies of the Anaesthetist Charts & the Operation Notes for our review so that we can understand the additional complexities involved during the surgery that may indicate that a higher fee may be warranted:

Multiple Specialists
Where two or more specialists operate on a member as a matter of preference, only a single fee is claimable.

Where two specialists perform different procedures and where the second procedure cannot be performed by a single specialist, then the two specialists will be treated separately for the purposes of this fee schedule. An example would be a mastectomy followed by a DIEP flap. These requests must be preauthorised and will be considered on a case by case basis, a justification letter will be required that clearly explains the medical need for additional specialists to be present, the procedure codes, the estimated time in theatre and requested fees (for each specialist) so that we can determine the appropriate level of reimbursement required . Please contact the specialist fees team via the following link

In any other circumstances where two specialists are required, this should be agreed in advance with the specialist fees team.

Fees Outside Of Our Billing Principles
Requests for additional fees for services that sit outside of our billing principles must be preauthorised & will be considered on a case by case basis. To review a request we will require a copy of the clinic letter sent back to the GP which relates to the specific treatment you are recommending and/or a justification letter detailing why this additional cost is warranted so that we can understand the clinical rationale for the recommended treatment and determine the appropriate level of reimbursement required. Please contact the specialist fees team via the following link

Consultation Charges
A consultation means a face-to-face consultation only. Only a single consultation may be claimed on any one day, consultation fees are set regardless of time or complexity. We do not provide benefit for consultations using electronic communication for example by email, telephone or across the internet. Consultation fees are inclusive of any room charges or any other additional charges.

In-patient care charges are claimable only by the physician in charge of the case and are for face to face visits and are not claimable for being on-call. Other specialists may claim benefit for specific consultations for specific problems only, but this should be pre-authorised. We consider out-patient follow-up within ten days of a surgical procedure to be an integral part of post-operative care and thus to be covered by the charge for the procedure and this would not be reimbursed as an extra service.

During the course of a members treatment we may need to request medical information or a Medical Information Form may need to be completed to obtain relevant information about a claim. We try to ensure that only the minimum amount of information is requested in order to service the request. Any medical information or Medical Information Form submitted must be completed and/or signed by the controlling specialist. Please note that we do not expect any charge to be made for the provision of this information or the completion of the report.

Anaesthetic Fees
The benefit for anaesthesia includes an amount for pre-operative assessment (whether on the ward or at a clinic), the anaesthetic itself including any lines or monitoring and post-operative care including analgesia, care in ITU or HDU, nerve blockage, neuroaxial blockade or epidural. None of these should be listed as extra. Operations should be coded using the single CCSD code which describes the operation performed plus all its component parts. Additional codes should only be used for genuine separate and additional procedures. There is no code for CVP lines as part of anaesthesia or ITU care and specifically the code L9110 should not be used.

Anaesthesia By The Operator
All procedure prices within the schedule are all inclusive of any charges for local/topical anaesthesia and IV sedation by the main operator. We will not pay extra if a separate charge is received for local/topical anaesthesia or IV sedation by main operator or from a separate anaesthetist. If you require any further advice please contact the Specialist Fees team via the following link

Intensive Care
For patients in intensive care which is medically necessary and not for routine care post-surgery, a fee is payable as indicated in this Schedule. This covers consultation, monitoring and procedures such as CVP lines, arterial lines and dialysis, pulmonary artery catheters etc. Additional fees may be claimed for procedures with a CCSD code and can be claimed by the specialist in primary charge of the case. Other specialists may claim for necessary consultations for specific problems but not a daily fee.

Chemotherapy Billing Principles
Charges for the prescribing and supervision of chemotherapy should be made in accordance with the schedule set out in Chapter 18.

A fee for consultation may be charged before treatment commences. Further consultation fees should not be charged during the course of treatment.

Chemotherapy Supervision
The coding covers all care relating to the clinical supervision and planning of the delivery of chemotherapy (only ONE of the following: X0001 OR X0002 OR X0003 OR X0004) regimens and the engagement and management of patients, including but not limited to:
  • Regime prescription
  • Supervision of planning and treatment delivery
  • Expected side effects management and the prescription of an alternative regimen
  • Supervision of all outpatient, day patient, and inpatient care

    Only one supervision fee will be paid for any course of treatment regardless of whether a single or multiple drug combination is used. We expect that invoices for chemotherapy and biological supervision should be made at the end of the cycle of treatment.

    Charges for the prescribing and supervision of radiotherapy should be made in accordance with the schedule set out in Chapter 20. As per CCSD guidance: it is intended that planning codes (X6000-X6099) are to be used by both consultants and hospital providers. Delivery codes (X7000-X7099) are to be used by hospital providers only and clinical supervision codes (X0007-X0012) are to be used by consultants only for delivery. Please see the CCSD Schedule for more information:

    A fee for consultation may be charged before treatment commences. Further consultation fees should not be charged during the course of treatment. These codes cover all care relating to the clinical supervision and planning of the delivery of radiotherapy regimens and the engagement and management of patients, including but not limited to:
  • Regime prescription
  • Supervision of planning and treatment delivery
  • Expected side effects management and the prescription of an alternative regimen
  • Supervision of all outpatient, day patient, and inpatient care, including any transfusion of blood/blood products.

    We expect that invoices for radiotherapy supervision and treatment delivery should be made at the end of the cycle of treatment.

    All Inclusive Fee Arrangements
    Our contracts with hospitals listed in our Network of Hospitals include some services where specialists’ fees are included within the prices we have agreed with the hospitals, notably diagnostic radiology, pathology and in-patient therapies. In these circumstances specialists should negotiate appropriate remuneration for their services with the hospital. This arrangement provides clarity and reassurance for patients that all charges associated with such services are covered under our contract with the hospital.

    All diagnostic radiology must be billed through the hospital in accordance with contracted rates. Therapeutic interventional radiology can be billed in accordance with fees contained in this Schedule.

    All pathology charges must be billed through the hospital or clinic where the procedure took place. Where the specimen is taken in a consulting room owned and managed by a consultant specialist, we will accept invoices from any recognised pathology facility with which we have a fee agreement.

    Facility, Consumable and Equipment Charges
    Charges may be made for facilities provided there is a formal agreement in place between the facility and AXA PPP healthcare. Consumable items (including drug costs) and equipment charges should be invoiced to AXA under the agreement of the facility unless there has been a prior arrangement made directly with AXA PPP healthcare. No charges should be made for any item which is not subject to a formal agreement.

    Submission of Claims

    In line with our members’ policies, all eligible claims must be submitted within six months of treatment. Invoices for eligible treatment must be submitted electronically and full treatment details must be provided to avoid processing delays. Electronic billing must be submitted via Healthcode & the following link

    When you open this link you should select the option to “register for HC VEDA”.


    Payment will be made by monthly interval payment. This will be accompanied by a remittance advice which provides a breakdown of the total amount paid, the members it relates to and any shortfalls in payment made such as shortfalls due to a policy excess. A similar remittance advice is also sent to the member advising them of any liability including an invoice to show the amount of any shortfall and to whom this should be paid. To support this payment, the member will also be provided with the details of the specialist's invoice address that was either submitted on the application form or more recently on a change of address form. Specialists are advised to consider this if they have provided a home rather than a business address for this purpose.

    Effective and Appropriate Medical Treatment

    We do not provide benefit for experimental or unproven procedures, including those using new technology or drugs, where safety and effectiveness have not been established or generally accepted. Please contact the Medical Department at AXA PPP healthcare before undertaking treatment which might fall into this category. Under no circumstances should codes intended for existing procedures be used for new and as yet uncoded procedures. The narratives and codes are protected by copyright and may not be altered or used in any other way except as published in the Schedule of procedures and fees.

    Fraud and Misrepresentation

    The Fraud Act 2006 sets out the legal definition of fraud and creates offences of fraud by false misrepresentation, fraud by omission and fraud by abuse of position. A person who makes a false statement, omits material facts or misuses a position of trust with the intention of causing loss to a third party is guilty of fraud even if he or she does not personally gain and even if the deception fails. The law includes false statement made to any device capable of receiving information. Home Office guidance on the application of the Act states that it is intended to cover false statements made to insurance companies at underwriting.

    Our business is conducted on the basis of good faith. We monitor claims using data mining software and routinely audit claims by reference to medical records. We will not tolerate fraud and misrepresentation and will cease doing business with any provider who provides false, misleading or selective information. We will also refer cases of fraud to the General Medical Council and to the police as appropriate. We consider the following examples constitute fraudulent billing:

    • Exaggeration of the complexity of the procedure performed for example coding a diagnostic procedure as if it were therapeutic.
    • Misrepresentation of the medical history or the procedure performed.
    • Omission of material facts.
    • The use of jargon or technical information which whilst strictly correct is presented in a way likely to mislead a non-medically qualified claims assessor (an example would be a claim for laser insitu keratomileusis (LASIK) coded as keratoplasty).
    • Unbundling.


    On occasion, we conduct audits of medical notes as part of our quality control procedures. Specialists and practitioners who are recognised by us for benefit purposes are required to provide this information on receipt of a consent form signed by the member authorising this disclosure.

    Network Policies

    The majority of our members (over 90%) have chosen to purchase a network policy which requires them to receive treatment at one of the facilities listed in our Directory of Hospitals. Under the terms of our network arrangement, we settle hospital charges in full for eligible treatment at any of these listed hospitals, but only a small daily benefit is paid if treatment is undertaken at a facility which is not in our Directory. This arrangement does not, however, compromise access to care that is medically necessary.
    Should a patient need facilities or treatments, which are not available at a convenient hospital in our Directory of Hospitals, then we will cover the costs of eligible treatment in full at whichever hospital is best able to provide the necessary care. However, this must be agreed with us before treatment takes place or, in an emergency, as soon as is possible after admission.

    To request an exemption, please complete a network exemption referral form which can be found at specialists/contact us/Network Exemption/PDF Hospital Exemption form and fax it to the number below. The Network team will review the clinical justification for an out-of-directory admission and confirm whether it will be eligible for full reimbursement.

    Network Exemption Team:

    Helpline: 01892 772218

    Fax: 0117 972 6006

    Failure to pre-authorise out-of-directory admissions may result in the member incurring a significant shortfall in benefit.
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