Policy Statement
Providers will not be reimbursed nor allowed to retain reimbursement for services considered to be Non-Reimbursable.
Services defined as Non-Reimbursable Services include, but are not limited to:
- Charges for the use of robotic surgical techniques must be reported and billed as separate line items on the itemized and electronic claims (e.g., S2900). These charges are not separately payable.
- Codes identified as not payable to professional providers and facilities (e.g., S9083 and S9088).
- Codes used in our specific health plan Programs when the provider is not contracted with, or the member not enrolled in that Program (e.g., S0281).
- Current Procedural Terminology (CPT®) category II supplemental tracking codes (e.g., 0001F).
- Drug testing CPT codes (e.g., 80320-80377 and 83992) as our health plan requires the use of the appropriate Healthcare Common Procedure Coding System (HCPCS) G codes.
- Evaluation and Management (E/M) visit complexity add-on code (i.e., G2211). Note: Commercial line of business only.
- HCPCS National ‘T’ codes established for state Medicaid agencies (e.g., T1000 and T5999), except for T1016 and T1017.
- Medicare clinical trial codes (e.g., G0293 and G0294).
- Medicare demonstration project codes (e.g., G9013 and G9140).
- Medicare status ‘B’ codes (e.g., 36416 and 90885). Note: an exception may be made by the plan for legislative or medical policy reasons.
- Postsurgical home use of an intermittent pneumatic compression device (PCD) (e.g., E0676) for the purpose of prevention of venous thrombosis is not eligible for reimbursement.
- Professional services for allergen immunotherapy, including provision of allergenic extract (e.g., 95120, 95125, and 95130-95134).
- Quality Measures (e.g., G8635 and G9188).
- Services that are included in a global payment (e.g., per diem or Diagnosis Related Group [DRG]) paid in a facility reimbursement and not separately payable to professional, laboratory or ancillary providers (e.g., 99026 and 99190). Facilities that are reimbursed at a global rate are responsible for the entire package of care that the member receives from, or which are ordered by, the facility during that stay.
- Some services that are not direct face-to-face patient care (e.g., 99375).
- Services for which our health plan does not contract (e.g., S0270-S0274).
- Services which our health plan considers part of another service and therefore not separately reimbursable (e.g., 94760 and 96904).
- Tests, procedures, or medical drugs that are considered obsolete in nature (e.g., P2028).
- Codes for which products are no longer available and/or have no National Drug Code (NDC) assigned.
Please refer to the Coding toolkit on the Provider Website for a comprehensive list of codes our health plan defines as Non-Reimbursable Services.
References
Cross References
- Med 106 - Urine Drug Testing
- Adm 134 - Pneumatic Compression Device
