Place of Service - Facility
Defines Anthem's reimbursement rules for when professional services must be billed on a CMS-1500 versus UB-04 claim forms, and specifies excluded revenue codes and settings; applies to Anthem commercial providers submitting claims for covered members.
Removed 'and Evaluation and Management' from policy title; added professional services billed under revenue codes 960-989 when submitted on a UB-04; added Preventive Counseling CPTs 99401-99404 & 99411 & 99412 when billed in an outpatient setting.
Place of Service Billing Rules
Place of Service billing criteria
Billing rules determining whether professional services are billed on CMS-1500 vs UB-04:
Place of Service billing rules
- UB-04 disallowed for professional services: Professional services shall not be billed on a UB-04 claim form unless provider, state, federal contracts and/or mandates indicate otherwise.
Services required on CMS-1500
- Evaluation and Management services rendered in an office, professional building, medical office building, clinic, or a space owned by a hospital or an institutional provider (other than the primary structure on the campus) or rented by a professional from the hospital or institutional provider must be billed on a CMS-1500 claim form.
- Evaluation and Management services rendered within the primary structure of a facility must be billed on a CMS-1500 claim form.
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