CurrentBlue Cross Blue Shield - MainePolicy C-26001

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.

Policy Summary

PayerBlue Cross Blue Shield - Maine

PolicyDrugs and Devices Requiring Procedures - Facility

Policy CodePolicy C-26001

Change TypeNo material change

Effective DateOct 1, 2026

Next Review Date

Key ActionReimbursement is allowed only when a drug or device is billed with a supporting procedure on the same claim; otherwise reimbursement will not be allowed.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

procedure requiredreimbursement condition for drugs/devices

outpatient facilityprovider setting

OCEsupporting-procedure list source

07/01/2026policy approval date

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CurrentBlue Cross Blue Shield - MainePolicy C-26001

Drugs and Devices Requiring Procedures - Facility

Customize your policy alerts

Sign up for Blue Cross Blue Shield - Maine Policy C-26001 alerts

Get alerted when Policy C-26001 changes without checking for updates manually.

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Policy Summary

PayerBlue Cross Blue Shield - Maine

PolicyDrugs and Devices Requiring Procedures - Facility

Policy CodePolicy C-26001

Change TypeNo material change

Effective DateOct 1, 2026

Next Review Date

Key ActionReimbursement is allowed only when a drug or device is billed with a supporting procedure on the same claim; otherwise reimbursement will not be allowed.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

procedure requiredreimbursement condition for drugs/devices

outpatient facilityprovider setting

OCEsupporting-procedure list source

07/01/2026policy approval date

Facility Reimbursement Criteria

Facility reimbursement criteria

Covered when ALL of the following are met:

Drug or device is billed by an outpatient facility provider on an outpatient facility claim.

A supporting procedure is billed on the same claim as the drug or device.

The requirement for a supporting procedure follows CMS Outpatient Code Edits (OCE).

If the drug or device is submitted without the supporting procedure, reimbursement will not be allowed.

Billing Requirements and Actions for Providers

Denial Risk

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

Definitions (referenced)

Definitions referencedGeneral reimbursement policy definitions are referenced in this document but not detailed here.

Where to find detailsSee the plan’s general reimbursement definitions resource for full term explanations used across Blue Cross Blue Shield - Maine policies.

Document scopeThis policy uses those definitions to interpret reimbursement requirements for outpatient facility drugs and devices requiring supporting procedures.

Terminology consistencyDefinitions ensure consistent interpretation of terms such as ‘supporting procedure’, ‘outpatient facility’, and ‘reimbursement allowed’.

Applicable Site of Care

Billing Rule

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).

Policy Summary

PayerBlue Cross Blue Shield - Maine

PolicyDrugs and Devices Requiring Procedures - Facility

Policy CodePolicy C-26001

Change TypeNo material change

Effective DateOct 1, 2026

Next Review Date

Key ActionReimbursement is allowed only when a drug or device is billed with a supporting procedure on the same claim; otherwise reimbursement will not be allowed.

SourceLink

On This Page

Drugs and Devices Requiring Procedures - Facility

Sign up for Blue Cross Blue Shield - Maine Policy C-26001 alerts

Drugs and Devices Requiring Procedures - Facility

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Facility Reimbursement Criteria

Coding and Source References

Billing Requirements and Actions for Providers

Definitions

Applicable Site of Care