Description
The purpose of this policy is to provide direction on how the Plan handles paying for services billed on a generic revenue code that does not require a HCPCS.
Policy
Outpatient medical claims that include revenue codes that do not require a HCPCS will be limited to 60% of charges. This policy applies to the following revenue codes:
- 0250 - 0259 (Pharmacy)
- 0270, 0271 and 0272 (Medical/Surgical Supplies – General)
- 0370 - 0379 (Anesthesia)
- 0637 (Self-Administered Drug(s))
Note: This policy does not apply to Enhanced Ambulatory Patient Groups (EAPGs) payments as HCPCS are required for EAPG payments. This policy also does not apply to providers that are paid on a percentage of charge.
Limitations and Exclusions:
While reimbursement is considered, payment determination is subject to, but not limited to:
- Group or Individual benefit
- Provider Participation Agreement
- Routine claim editing logic, including but not limited to incidental or mutually exclusive logic, payment integrity edits and medical necessity
- Mandated or legislative required criteria will always supersede.
In instances where the provider is participating, based on member benefits, co-payment, coinsurance, and/or deductible shall apply.
Cross References
Official UB-04 Data Specifications Manual
History:
Date
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Updates
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8/24/2020
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Note was added regarding 102% rate adjustment.
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10/15/2020
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Added a note that this policy does not apply to EAPG payments.
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2/02/2022
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Updated formatting
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9/22/2022
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Note removed on % increases
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8/23/2023
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Policy annual review completed
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9/15/2024
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Policy annual review completed
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9/1/2025
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Added clarifying language regarding providers paid on a percentage of charge.
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