CurrentBlue Cross Blue Shield - MainePolicy C-17005

Multiple Diagnostic Imaging Facility Reimbursement

Governs facility reimbursement rules when multiple diagnostic imaging procedures (ultrasound, CTA, CT, MRI, MRA) are performed in the same facility, same imaging session, for Anthem Blue Cross and Blue Shield commercial members billed on UB-04; applies unless provider/state/federal contracts or mandates indicate otherwise.

Policy Summary

PayerBlue Cross Blue Shield - Maine

PolicyMultiple Diagnostic Imaging Facility Reimbursement

Policy CodePolicy C-17005

Change TypeNo material change

Effective DateJun 13, 2023

Next Review DateN/A

Key ActionBill services on UB-04 and apply 100% of the highest facility allowance for the first imaging procedure and 50% for each subsequent procedure on the same date of service.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

100% / 50%Reimbursement rule

ultrasound, CTA, CT, MRI, MRAImaging types

UB-04Billing form

TC modifier includedCoding note

Multiple Diagnostic Imaging Facility Reimbursement Criteria

Multiple diagnostic imaging facility reimbursement criteria

When two or more diagnostic imaging procedures are performed in the same facility, on the same member, using the same modality, during the same imaging session:

Reimbursement is 100% of the highest facility allowance for the first imaging procedure on the date of service

Reimbursement is 50% of the facility allowance for each subsequent diagnostic imaging procedure on the same date of service

Applies to ultrasound, computed tomographic angiography (CTA), computed tomography (CT), magnetic resonance imaging (MRI), and magnetic resonance angiography (MRA) procedures eligible for reimbursement

Multiple diagnostic imaging reimbursement rules are applied to the highest facility allowance of the diagnostic imaging procedures rendered on the same date of service

Policy Summary

PayerBlue Cross Blue Shield - Maine

PolicyMultiple Diagnostic Imaging Facility Reimbursement

Policy CodePolicy C-17005

Change TypeNo material change

Effective DateJun 13, 2023

Next Review DateN/A

Key ActionBill services on UB-04 and apply 100% of the highest facility allowance for the first imaging procedure and 50% for each subsequent procedure on the same date of service.

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.

Modifiers and Reimbursement Rules

Modifiers referencedModifier

LT	Left side modifier; used to report bilateral services on separate lines when required
RT	Right side modifier; used to report bilateral services on separate lines when required
TC	Technical component modifier; technical component charges may be billed using modifier TC; reimbursement for subsequent procedures based on 50% of fee allowance

TC technical component detailsModifier

TC	Under certain circumstances, a charge may be made for the technical component alone; reimbursement for subsequent procedures is based on 50% of the fee allowance

Multiple imaging reimbursement rule (summary)

Multiple imaging reimbursement ruleReimbursement is 100% of the highest facility allowance for the first imaging procedure on the date of service and 50% of the facility allowance for each subsequent diagnostic imaging procedure on the same date/session.

Applies whenTwo or more diagnostic imaging procedures are performed in the same facility, on the same member, using the same modality during the same imaging session.

Covered diagnostic imaging typesUltrasound; computed tomographic angiography (CTA); computed tomography (CT); magnetic resonance imaging (MRI); magnetic resonance angiography (MRA).

Billing formApplies to UB-04 submitters billing CPT and HCPCS (Level II) codes for the listed diagnostic imaging procedures.

Superseding rulesPolicy applies unless provider, state, or federal contracts/mandates indicate otherwise.

Authorization, Medical Necessity, and Billing

Prior Authorization

Authorization, medical necessity, and accurate billing required

Services must meet authorization and medical necessity guidelines appropriate to the procedure and diagnosis, and follow proper billing and submission guidelines. Use industry-standard CPT, HCPCS and/or revenue codes and ensure claims are fully supported in the medical record or office notes; failure to follow coding/billing guidelines may result in recoupment, claim rejection, or denial.

Ensure services meet authorization and medical necessity requirements for the procedure, diagnosis, and member's state of residence.
Bill using Current Procedure Terminology (CPT), HCPCS and/or revenue codes as applicable and support billed services in the medical record or office notes.
Follow UB-04 billing for facility claims as required by this policy; apply LT/RT and TC modifiers per coding guidance when applicable.
Be aware Anthem may recover/recoup payment or reject/deny claims if coding/billing guidelines or reimbursement policies are not followed.

OpenPayer

Multiple Diagnostic Imaging Facility Reimbursement

Multiple Diagnostic Imaging Facility Reimbursement Criteria

Modifiers and Reimbursement Rules

Authorization, Medical Necessity, and Billing

Key Definitions