CurrentBlue Cross Blue Shield - Rhode IslandPolicy N/A

Not Separately Reimbursed / Non‑reimbursed Codes

Governs BCBSRI payment stance that certain CPT/HCPCS codes are covered but not separately reimbursed (packaged or included in other services) for professional and institutional providers; applies to Medicare Advantage and commercial products with variations by product and contract.

Policy Summary

PayerBlue Cross Blue Shield - Rhode Island

PolicyNot Separately Reimbursed / Non‑reimbursed Codes

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateJan 6, 2013

Next Review DateJan 4, 2026

Key ActionProviders must verify member eligibility and benefits with the provider call center for member-specific questions.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

updated quarterlyfrequency of list updates

MA & Commercialproduct applicability

Category II excludedcodes not reimbursed

status 'N' = NSROPPS mapping

Not Separately Reimbursed / Alternate Code Criteria

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Not Separately Reimbursed / Alternate Code Criteria

Covered when meeting the operational rules below:

Codes listed are considered covered but are not separately reimbursable; payment is included in the allowance for another service or will not be reimbursed separately even if filed alone.

Product/Contract Variation

Reimbursement may vary by product (Medicare Advantage vs Commercial) and by group/contract; refer to the Benefit Booklet, Evidence of Coverage, or Subscriber Agreement for applicable benefits/coverage.

CMS OPPS 'N' status codes are generally treated as covered but not separately reimbursed (packaged) in BCBSRI claims processing.

Category II CPT/HCPCS codes (performance measurement codes) are excluded from reimbursement as they are intended for data collection/quality measurement rather than payment.

If an equivalent CPT/HCPCS exists, providers should report the service using the alternate code when indicated.

The list of non‑reimbursed/alternate codes is maintained separately (excel workbook) and is updated quarterly; the attached workbook reflects code status as of January 1, 2025. Contact Customer Service for specific coverage details.

'Not Separately Reimbursed' (NSR) services are not billable to the member. Note that some codes may be NSR only for specific ages or provider types.

Providers must verify member eligibility and benefits with the provider call center; this policy is informational and is not a guarantee of payment.

Code Listings and Coding Guidance

Category II / Performance Measurement CodesCPT | HCPCSNot Covered

Category II (XXXXF/GXXXX/MXXXX)

Performance measurement codes not intended for reimbursement

Not Separately Reimbursed / Packaged CodesmixedNot Covered

OPPS status indicator N	Codes with status 'N' are generally covered but not separately reimbursed (packaged)
NSR (Not Separately Reimbursed)	Covered but not separately reimbursable; not billable to the member

Alternate Code GuidanceCPT | HCPCS

Use Alternate Code

Report service using an equivalent CPT/HCPCS code when indicated

Effective code status workbook date

Effective workbook dateCode status workbook reflects professional & institutional provider status as of January 1, 2025

Product applicabilityApplies to Medicare Advantage and Commercial products; reimbursement may vary by product or contract

Update cadenceWorkbook is the authoritative list for current code status (see policy for update schedule)

Provider Responsibilities and Billing Actions

Prior Authorization

Not applicable.

Note

Provider verification

For member-specific benefits or coverage questions, call the provider call center. The provider must verify eligibility and benefits for each member prior to rendering services.

Verify member eligibility and benefits through the provider call center before scheduling or billing services.
Do not rely solely on this policy for coverage determinations; the subscriber agreement, member certificate, or employer agreement governs benefits.

Key Definitions

Not Separately Reimbursed (NSR)

Definition'Not Separately Reimbursed' (NSR) = a code that is covered but not a separately reimbursable service

Billing implicationServices designated NSR are not billable to the member

Scope notesSome codes may be NSR only for specific ages or provider types; check workbook for exceptions

Category II Codes

DefinitionCategory II CPT/HCPCS codes (XXXXF, GXXXX, MXXXX) are performance measurement codes used for data collection and quality measurement

Reimbursement stanceCategory II codes are not intended to be used for reimbursement and are excluded from the NSR list

PurposeUsed to capture services and results that support nationally established performance measures

OPPS Status Indicator N

DefinitionOPPS status indicator 'N' = CMS designation where payment is considered packaged into other services (not paid separately)

BCBSRI mappingBCBSRI generally sets codes with OPPS status 'N' as covered but not separately reimbursed in its claims system

Implication for providersWhen CMS classifies a code as 'N', BCBSRI typically treats it as packaged (NSR); verify exceptions in the workbook