Non-Reimbursable Services

Policy No: 107
Originally Created: 12/01/2009
Section: Administrative
Last Reviewed: 01/01/2019
Last Revised: 01/01/2018
Approved: 02/07/2019
Effective Date: 03/01/2019

This policy applies to ASCs, physicians, other qualified health care professionals, hospitals and other facilities.


Non-Reimbursable Services
Services that are not eligible for reimbursement.

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:

  • 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.



Cross References

Urine Drug Testing


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