CurrentAnthemPolicy C-14002

Clinic Charges - Facility, Commercial Reimbursement Policy

Governs reimbursement for clinic services billed by facilities or health systems and requires clinic services rendered in office-type settings to be billed on professional (CMS-1500) claims rather than UB-04 facility claims; affects facilities, hospitals, professional providers, and Anthem commercial members.

Policy Summary

PayerAnthem

PolicyClinic Charges - Facility, Commercial Reimbursement Policy

Policy CodePolicy C-14002

Change TypeNo material change

Effective DateJul 21, 2025

Next Review Date

Key ActionBill clinic services on a CMS-1500 claim form when rendered in office-type settings and do not bill those services on a UB-04.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

CMS-1500 requiredClaim form required for clinic services rendered in office settings

UB-04 disallowedClinic services billed on UB-04 by facility are not reimbursable

051X-0529Related revenue codes listed in policy history and coding sections

No exemptionsPolicy states there are no exemptions

Clinic Billing and Coverage Rules

Policy Summary

PayerAnthem

PolicyClinic Charges - Facility, Commercial Reimbursement Policy

Policy CodePolicy C-14002

Change TypeNo material change

Effective DateJul 21, 2025

Next Review Date

Key ActionBill clinic services on a CMS-1500 claim form when rendered in office-type settings and do not bill those services on a UB-04.

SourceLink

On This Page

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

Clinic billing and coverage rules

Covered when all of the following rules are met:

Clinic services rendered at any clinic owned, operated, or controlled by a facility or health system are not reimbursable if billed on a UB-04 claim form.

Clinic services rendered in an office, professional building, medical office building, free-standing clinic, or any space on a facility campus (owned or rented) must be billed on a CMS-1500 claim form.

The facility or health system must seek reimbursement for any claimed technical or overhead component of clinic charges only from the professional provider and not from the health plan or the member.

Facility providers should not bill the health plan for off-campus clinic charges for any technical component or overhead expenses of a covered service, including use of the space where professional services are provided.

When services are essentially office visits, the professional provider should bill place of service code 11 and the member will not be responsible for clinic charges billed by the hospital/institution/health system.

There are no exemptions to this policy.

This policy is subject to federal and state laws and the terms, conditions, and limitations of a member's benefits; providers must follow applicable authorization and medical necessity requirements.

Related Revenue and Billing Codes

Clinic revenue codes (051X - 0519)Revenue

0510	General Clinic
0511	Chronic Pain Center
0512	Dental Clinic
0513	Psychiatric Clinic
0514	OB/GYN Clinic
0515	Pediatric Clinic
0516	Urgent Care Clinic
0517	Family Practice Clinic
0519	Other Clinic

Freestanding clinic revenue codes (052X - 0529)Revenue

0520	General Freestanding Clinic
0521	Clinic Visit by Member to RHC/FQHC
0522	Home Visit by RHC/FQHC Practitioner
0523	Family Practice Clinic
0526	Urgent Care Clinic
0527	Visiting Nurse Services to a member's home when in a home health shortage area
0528	Visit by RHC/FQHC Practitioner to other non-RHC/FQHC site (e.g., Scene of Accident)
0529	Other Freestanding Clinic

Claim Form, Authorization, and Billing Guidance

Prior Authorization

Claim Form and Authorization Guidance

Claim form and authorization guidance: Clinic services must be billed on a CMS-1500 (professional) claim form when rendered in an office, professional building, medical office building, free-standing clinic, or any space on a hospital/health system campus that is owned or rented by a professional. The health plan does not reimburse clinic services billed on a UB-04 (facility) claim form when the clinic is owned, operated, or controlled by a facility or health system unless provider, state, federal contracts, or other requirements specifically indicate otherwise. Facility providers should not bill the Health Plan for off-campus clinic charges for any technical component or overhead expenses of a covered service, including use of the space where the professional services are provided. The professional provider should bill place of service code 11 (office) when services are essentially office visits. The facility or health system must seek reimbursement for any technical or overhead component only from the professional provider, not from the plan or the member. Services must meet applicable authorization and medical necessity requirements and be billed using industry-standard CPT/HCPCS/revenue codes fully supported in the medical record; failure to follow required billing, coding, or authorization guidelines may result in claim rejection, denial, or recoupment.

Bill clinic services on CMS-1500 when rendered in: office; professional building; medical office building; free-standing clinic; any space on a hospital/institution/health-system campus that is owned by the hospital or rented by a professional.
Do not bill clinic services on UB-04 if the clinic is owned, operated, or controlled by a facility or health system (unless specific contracts/regulations allow).
Facility/providers should not seek reimbursement from the Health Plan for technical/overhead components of clinic charges—these should be sought from the professional provider.
Professional provider: use place of service code 11 for services that are essentially office visits.
Ensure prior authorization and medical necessity criteria are met and document CPT/HCPCS/revenue codes in the medical record; improper billing/authorization may lead to claim rejection, denial, or recovery.

Definitions Relevant to Policy Scope

Owned, operated, or controlled by a facility or health system

DefinitionAn entity is wholly owned by the hospital if the hospital is the sole owner; an entity is wholly operated by the hospital if the hospital has exclusive responsibility for conducting and overseeing the entity’s routine operations, regardless of whether the hospital also has policy‑making authority over the entity.

ScopeApplies to entities owned, operated, or controlled by a facility or health system when determining billing responsibility for clinic services.

Implication for billingClinic services rendered at entities meeting this definition should be billed on professional (CMS‑1500) claims rather than UB‑04 facility claims per policy guidance.

ResponsibilityThe facility/hospital retains operational control or ownership as described; professional providers should seek reimbursement on professional claims and facilities should not bill Anthem for technical/overhead clinic charges.

ReferenceSee General Reimbursement Policy Definitions for full definition text and applicability to clinic billing rules.