CurrentArizona Complete HealthPolicy CC.PI.10

Unbundling Adjustments on Clean Claim Reviews

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

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.

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.

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.

OpenPayer

Unbundling Adjustments on Clean Claim Reviews

Criteria for Separate Reimbursement and Exclusions

Implants, Routine Services, and Coding Notes

Vendor Review and Claims Processing Responsibilities

Key Term Definitions