CurrentArizona Complete HealthPolicy CC.PI.10
Unbundling Adjustments on Clean Claim Reviews
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Defines how facility billed charges are evaluated for unbundling during clean claim reviews and who must follow the process across the Company.
Policy Summary
PayerArizona Complete Health
PolicyUnbundling Adjustments on Clean Claim Reviews
Policy CodePolicy CC.PI.10
Change TypeNo material change
Effective DateSep 1, 2022
Next Review DateN/A
Key ActionPayment Integrity manages vendors who perform clean claim reviews and Claims Operations processes payment based on their findings.
SourceLink
POLICY UPDATE CHANGES
No material clinical or coverage changes in this revision.
All productsapplies to
10+enumerated procedure items
Multiplenon-reimbursable examples
CC.PI.10internal id
Criteria for Separate Reimbursement and Exclusions
Separate reimbursement criteria
Criteria for supplies/services to be separately payable:
ALL of the following
- Supply or service must be medically necessary and reasonable for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member.
- Supply or service must be furnished at the direction of a physician (by distinct physician order).
- Supplies that are generally available to all patients billed at the same underlying room and board acuity level and/or ordinarily furnished to patients during the course of a procedure are not separately payable (cost included in underlying charge).
- Supplies, items, pharmaceuticals, and services that are necessary or otherwise integral to the provision or delivery of a specific underlying service are not separately payable.
- Items and supplies that may be purchased over the counter are not separately payable.
- Supply fees billed daily or one time which are unidentified and unsupported by medical records or documentation are not reimbursable.
- Blood and blood product administration services (including thawing/pooling fees) are not separately reimbursable on inpatient claims.
- Pharmacy charges include the cost of drugs; additional separate charges for drug administration, preparation materials, or services of pharmacy personnel are not payable.
- Multiple charges for results obtained from the same underlying blood sample analysis are not separately reimbursed; costs are reimbursed per blood sample analysis performed.
- Operating room charges include routine supplies and equipment (linen packs, instrument packs, sutures, gloves, drapes, prep kits, robotic technology, etc.) and these are not separately reimbursable.
- Charges for reusable items, supplies and equipment are not separately payable when use does not result in an incremental cost.
- All charges are subject to review to confirm billed amounts reasonably and consistently relate to underlying direct and indirect costs.
(Note) This set of criteria defines when facility-billed supplies and services qualify for separate reimbursement versus being included in the underlying room/procedure charge.
Non-reimbursable examples
Examples of items not separately reimbursable (non-exhaustive):
ANY of the following
- Admission kits
- Anesthesia supplies, including pharmaceuticals/gases when billed with anesthesia time charges
- Any linen (bedsheets, towels, etc.)
- Bedpans/Urinals
- Beds/Mattresses
- Bili light
- Bladder scans
- Blood pressure cuffs and monitors (including disposable cuffs)
- Breast milk/storage supplies
- Capital equipment
- Cardiac monitors
- Catheters (routine) / Foley/Straight catheters
- Cotton balls
- CPR
- CRRT / Dialysis supplies
- Diapers
- Disposable towels
- Drapes / Preparation drapes / surgical drapes
- Dressing change trays/packs/kits; Dressings/Gauze/Sponges
- Enteral/Parenteral feeding supplies (tubing, bags, sets, etc.)
- Education/training charges
- Facility personnel charges (lactation consultants, dietary consultants, transport fees, professional therapy functions)
- Gloves/Gowns/Covers/Blankets
- Heat lights/Heating pads; Ice packs/Water bottles
- Injections (vaccine administration) and medication preparation
- Internal transports / patient transport
- Investigational/experimental items
- Irrigation solutions; Isolation supplies; Isolettes
- IV infusions/IV push; IV line flushes and solutions; IV supplies and insertion kits; IV solutions used to dilute medications
- Kerlix/Tegaderm/OpSite/Telfa; Lotion; Masks (oxygen, CPAP, nasal cannulas/prongs, etc.)
- Meal trays; Personal convenience items; Portable charges; Replacement batteries
- Monitoring supplies (electrodes, cables, wires, oxygen sensors, capnography, end tidal CO2, etc.); Point of Care monitoring and testing
- Operating room equipment and supplies (saws, skin staplers, staples, sutures, scalpels, blades, instrument trays, surgical packs, gowns, etc.)
- Perfusion supplies when billed with perfusionist time charges; Preparation kits; Preparation or set-up charges; Pressure/Pump transducers
- Personal convenience items (televisions, slippers, etc.)
- Pressure/Pump transducers; Pacing cables/wires/probes; Razors
- Rental fees; Replacement batteries; Restraints
- Reusable items; Routine nursing services; Separate nursing charges
- Saline solutions; SCD Sleeves/Compression sleeves/TED hose; Stockings; Socks; Soap; Skin cleansers/preps; Skin temperature probes
- Specimen collection devices, containers, and fees (venipuncture, phlebotomy, heel stick, etc.); Stat charges; Sputum induction/Sputum trap
- Suction supplies (canisters, tubing, tips, catheters, liners, wall suction); Suction supplies
- Syringes/Needles/Lancets/Butterflies; Tape; Tongue depressors; Thermometers/Temperature probes
- Telemetry and monitoring supplies; Video systems; Wall suction
- Underpads; Urometers/Leg Bags/Tubing; Tracheostomy care/Changing of cannulas; Traction equipment; Transducer kits/packs
- Wipes (baby, cleansing, etc.); Odor eliminator/Room deodorizer
(Note) The list above is illustrative and not exhaustive; other similar routine supplies and equipment may also be included in underlying charges and are not separately reimbursable.
Implants, Routine Services, and Coding Notes
Implant (definition)mixed
| Implant | 'Implant' is an object, device or material that is inserted surgically, or embedded via surgical or nonsurgical means, or grafted into the body and remains in the body either indefinitely for prosthetic and/or therapeutic purposes or remains in the body for a temporary or provisional period of time for diagnostic and/or therapeutic purposes. |
Routine Services (CMS definition)mixed
| Routine Services | Section 2202.6 of the CMS Provider Reimbursement Manual: 'Inpatient routine services ... are those services included by the provider in a daily service chargessometimes referred to as the 'room and board' charges…Included in routine services are the regular room, dietary and nursing services, minor medical and surgical supplies, medical social services, psychiatric social services, and the use of certain equipment and facilities for which a separate charge is not customarily made.' |
Charges/Items considered integral or not separately payablemixed
| Integral supplies/services | Supplies, items, pharmaceuticals, and services that are necessary or otherwise integral to the provision of a specific underlying service and/or the delivery of such underlying service(s) are not separately payable. |
| OTC items | Items and supplies that may be purchased over the counter are not separately payable. |
| Unidentified supply fees | Supply fees billed daily or one time, which are unidentified and unsupported by medical records or documentation are not reimbursable. |
| Blood administration | Blood and blood product administration services are not separately reimbursable on inpatient Claims; thawing/pooling fees are not separately reimbursable. |
| Pharmacy charges | Pharmacy charges include the cost of the drugs; no additional separate charge for administration, preparation materials, or pharmacy personnel services. |
| Multiple lab charges | Costs for each blood sample analysis are reimbursed once; multiple charges for results obtained from the same underlying blood sample analysis are not separately reimbursed. |
| Operating room supplies/robotics | Operating room charge includes linen packs, basic instrument packs, dressings, equipment, routine supplies (sutures, gloves, dressings, sponges, prep kits, drapes, surgical attire); instrument trays and robotic technology are included and not separately reimbursable. |
| Reusable items | Charges for reusable items, supplies and equipment are not separately payable if use does not result in incremental cost. |
Vendor Review and Claims Processing Responsibilities
Documentation Required
Vendor review and claims processing roles
Payment Integrity manages the vendor(s) who conduct the clean claim reviews. Claims Operations processes payment of the member claim based on the findings identified in the clean claim reviews.
Key Term Definitions
Implant
Definition'Implant' — an object, device or material that is inserted surgically, or embedded via surgical or nonsurgical means, or grafted into the body and remains in the body either indefinitely for prosthetic and/or therapeutic purposes or remains in the body for a temporary or provisional period of time for diagnostic and/or therapeutic purposes.
PurposeUsed for prosthetic, therapeutic, or diagnostic purposes when implanted or grafted into the body.
DurationMay remain indefinitely or for a temporary/provisional period depending on clinical intent.
Context within policyImplants are evaluated during clean claim 'Unbundling' reviews to determine if they are separately payable or included in underlying procedure/room charges.
Payer obligationCompany must review facility charges prior to payment to identify potential improper implant billing as part of clean claim reviews.
Routine Services (CMS ref.)
CMS sourceSection 2202.6, CMS Provider Reimbursement Manual — defines inpatient routine services as those included in daily service charges ('room and board'), including nursing, minor medical and surgical supplies, medical social services, and use of certain equipment for which a separate charge is not customarily made.
Included services examplesRegular room, dietary and nursing services, minor medical and surgical supplies, medical social services, psychiatric social services, and certain equipment/facilities use.
Policy applicationRoutine services are considered not separately payable and are evaluated as part of the Company's unbundling/clean claim reviews to exclude them from separate reimbursement.
Purpose of citationProvides the authoritative definition the Company uses to identify which inpatient supplies/services are 'routine' and typically included in daily charges.
Policy Summary
PayerArizona Complete Health
PolicyUnbundling Adjustments on Clean Claim Reviews
Policy CodePolicy CC.PI.10
Change TypeNo material change
Effective DateSep 1, 2022
Next Review DateN/A
Key ActionPayment Integrity manages vendors who perform clean claim reviews and Claims Operations processes payment based on their findings.
SourceLink
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