Policy No: 107
Originally Created: 12/01/2009
Last Reviewed: 01/01/2019
Last Revised: 01/01/2018
Effective Date: 03/01/2019
This policy applies to ASCs, physicians, other qualified health care professionals, hospitals and other facilities.
Services that are not eligible for reimbursement.
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:
- Allergen provision plus administration combined codes. Services must be broken out and reported using separate codes representing each service (95120-95134).
- Chronic Care Case Management Services (99490) on non Medicare Advantage products/lines of business (this code is payable for Medicare Advantage products)
- Codes identified as not payable to professional providers (e.g. S9083).
- 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).
- Computer assisted musculoskeletal surgical navigational procedures (20985 0054T 0055T).
- Current Procedural Terminology (CPT®) category II supplemental tracking codes (0001F).
- Drug testing CPT codes (80320-80377, 83992) as our health plan requires the use of the appropriate Healthcare Common Procedure Coding System (HCPCS) G codes.
- HCPCS National "T" codes established for state Medicaid agencies (T1000-T5999).
- Medicare clinical trial codes (G0293-G0294).
- Medicare demonstration project codes (G9013-G9140).
- Medicare status 'B' codes (e.g. 36416, 90885). Note: an exception has been made for genetic counseling code 96040 as it specifically relates to Patient Protection and Affordable Care Act (PPACA) preventive legislation and our health plan medical policy.
- Quality Measures (e.g., G8635-G8976, G9188).
- Services that are included in the facility reimbursement and not separately payable to professional providers (e.g. 99026 99190).
- Services that are not direct face-to-face patient care (e.g. 99375).
- Services for which our health plan does not contract (S0270-S0274).
- Services which our health plan considers part of another service and therefore not separately reimbursable (e.g. 94760 96904).
- State Medicaid alcohol and drug abuse treatment services (e.g. H0001 H2013).
- Surgical techniques requiring use of robotic surgical system (S2900 - list separately in addition to code for primary procedure).
- Tests, procedures or medical drugs that are considered obsolete in nature (e.g. 92560, P2028).
- Codes for which products are no longer available and/or have no National Drug Code (NDC) assigned (e.g. 90660)
Please refer to the Coding Toolkit for a comprehensive listing of codes our health plan defines as Non-Reimbursable Services.