Drugs and Devices Requiring Procedures - Facility
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Governs reimbursement for drugs and devices billed by outpatient facility providers that require a supporting procedure on the same claim; affects facility providers submitting outpatient drug/device charges to Blue Cross Blue Shield - Maine.
No material clinical or coverage changes in this revision.
Facility Reimbursement Criteria
Facility reimbursement criteria
Covered when ALL of the following are met:
Coding and Source References
| No codes listed |
Billing Requirements and Actions for Providers
Bill drug/device with required supporting procedure or risk denial
The health plan allows reimbursement for a drug or device only when it is billed on the same claim as the required supporting procedure; claims for drugs or devices submitted without the supporting procedure will not be reimbursed.
- Requirement applies to outpatient facility providers.
- Supporting procedure list is based on CMS Outpatient Code Edits (OCE).
Definitions
Applicable Site of Care
Hospital outpatient claims must include supporting procedure
Applies specifically to hospital outpatient (outpatient facility) providers: reimbursement is allowed only when the drug or device is billed with the supporting procedure on the same outpatient facility claim; omission of the procedure will result in non-payment.
- Policy aligns supporting-procedure requirements with CMS Outpatient Code Edits (OCE).
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