CurrentBlue Cross Blue Shield - Rhode IslandPolicy N/A

Payment — Hospital-Based Clinics

Governs claim and reimbursement guidelines for services rendered in hospital-based clinics by physicians and midlevel practitioners for Blue Cross & Blue Shield of Rhode Island (BCBSRI) members.

Policy Summary

PayerBlue Cross Blue Shield - Rhode Island

PolicyPayment — Hospital-Based Clinics

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateJun 15, 2010

Next Review DateN/A

Key ActionProviders credentialed as Primary Care Physician or Dual Provider must bill services on CMS-1500 using Type 1 NPI for dates of service on or after 2019-08-01.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

8/1/2019billing change effective

051Xclinic revenue code

RequiredType 1 NPI

ExcludedLab/radiology

Hospital-based clinic coverage criteria

Policy Summary

PayerBlue Cross Blue Shield - Rhode Island

PolicyPayment — Hospital-Based Clinics

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateJun 15, 2010

Next Review DateN/A

Key ActionProviders credentialed as Primary Care Physician or Dual Provider must bill services on CMS-1500 using Type 1 NPI for dates of service on or after 2019-08-01.

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.

Hospital-based clinic services follow BCBSRI policy for facility global reimbursement and billing.

Clinic global rate applies to services rendered by non-Primary Care Physicians or non-Dual Providers: professional services, drugs, administration and supplies are included in the global fee (laboratory and radiology excluded).

Claims for services rendered by non-Primary Care Physicians or non-Dual Providers must be filed on UB-04 with the clinic revenue code (051X family) with the appropriate fourth digit for clinic type and the applicable CPT/HCPCS procedure code(s).

All claims must be billed with the rendering provider's Type 1 NPI.

Providers credentialed as Primary Care Physicians or Dual Providers must bill services on a CMS-1500 using the Type 1 NPI and appropriate Evaluation and Management (E/M) or preventive CPT/HCPCS codes (for example, 99xxx series, G0438/G0439) for dates of service on or after 2019-08-01; BCBSRI permits Place of Service 11 when filing CMS-1500 for these services.

Benefits and coverage for clinic services may vary by contract; refer to the member's Benefit Booklet, Evidence of Coverage, or Subscriber Agreement for applicable clinic benefits.

Required billing and coding

Required billing codes and revenue codesmixedCovered

051X	Clinic revenue code family with appropriate fourth digit for clinic type
CPT/HCPCS	Appropriate CPT/HCPCS procedure codes required for services rendered (E/M codes, preventive codes such as G0438/G0439 where applicable)

Billing form requirement by provider credentialing

RequirementProviders credentialed as Primary Care Physician or Dual Provider must bill services on CMS-1500 using their Type 1 NPI for dates of service on or after 2019-08-01.

Required form for PCP/Dual ProvidersCMS-1500 with appropriate Evaluation and Management codes (e.g., 99000 series, G0438/G0439 where applicable).

Place of Service guidanceBCBSRI allows claims filed on a CMS-1500 to be billed with Place of Service 11 (Office).

Non-Primary Care/Non-Dual ProvidersNon-Primary Care Physicians and non-Dual Providers shall continue to bill services on a UB-04 form.

PurposeBilling on CMS-1500 with Type 1 NPI ensures correct subscriber benefit application and accurate primary care physician attribution.

Key definitions

Hospital-based clinic definition

DefinitionHospital-based clinic: outpatient service providing preventive, diagnostic, therapeutic, rehabilitative, or palliative services as defined by CMS.

ExclusionsDefinition does not include clinics exclusively providing laboratory, testing, pharmacy, educational services, X-ray or therapy.

Coding roleBCBSRI utilizes revenue codes in combination with CPT/HCPCS codes to identify clinic type and determine appropriate benefits.

Clinic global rate

Scope of clinic global rateFacility reimbursement for services rendered by non-Primary Care or non-Dual Providers is paid as a global fee to the facility and BCBSRI will not separately pay the non-Primary Care Physician/non-Dual Provider for the hospital-based clinic visit.

Included in global feeProfessional services, drugs, administration and supplies provided as part of the clinic visit are included in the global fee.

Excluded from global feeLaboratory and radiology services obtained during the clinic visit are not included and are reimbursed separately according to applicable benefits.

Billing requirementClaims should be filed using the clinic revenue code (051X family with appropriate fourth digit) and the appropriate CPT/HCPCS code for services rendered.

OpenPayer

Payment — Hospital-Based Clinics

Hospital-based clinic coverage criteria

Required billing and coding

Provider actions and requirements

Key definitions