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.
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: Any applicable fee schedule percentage increases will be applied after the 60% of charges is calculated.
Note: This policy does not apply to Enhanced Ambulatory Patient Groups (EAPGs) payments as HCPCS are required for EAPG payments.
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, 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.
Official UB-04 Data Specifications Manual
Note was added regarding 102% rate adjustment.
Added a note that this policy does not apply to EAPG payments.