CurrentBlue Cross Blue Shield - WisconsinPolicy N/A

Hospital Clinic Visit facility reimbursement

Defines Anthem Blue Cross and Blue Shield's reimbursement stance for facility clinic visits delivered in outpatient/ambulatory settings and which providers/entities may bill; applies to members covered under Anthem Plan products (except Medicare Supplemental).

Policy Summary

PayerBlue Cross Blue Shield - Wisconsin

PolicyHospital Clinic Visit facility reimbursement

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateNov 1, 2009

Next Review DateN/A

Key ActionDo not bill facility clinic visit UB-04 revenue codes 510-525, 527-529 for separate facility reimbursement; report covered clinic visit services on CMS-1500 with place of service 'office' so professional providers receive reimbursement including overhead.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

professional providers onlyReimbursed to

UB-04 510-525,527-529 deniedFacility billing

Medicare SupplementalExclusions

held harmlessMember protection

Facility Clinic Visit Coverage Criteria

Facility clinic visit coverage criteria

Coverage and billing rules for facility clinic visits:

Anthem reimburses professional providers for covered services provided in a facility clinic setting when reported on a professional CMS-1500 form with a place of service office; this reimbursement includes professional services plus associated overhead.

The technical and overhead component of the facility clinic visit is included in the maximum allowable benefit paid to the professional provider; the facility may not seek reimbursement for any technical or overhead component of the clinic charge from Anthem or the member, and the member is held harmless for these clinic overhead charges.

Anthem will not separately reimburse a facility for clinic visits and services billed on a UB-04 when reported with revenue codes 510-525, 527-529 and any successor codes, unless there is a contractual arrangement to provide specific disease management services using these revenue codes.

If a contractual arrangement exists for disease management services, the facility may bill using those revenue codes but must report the appropriate CPT/HCPCS code associated with the disease management service rendered.

Policy Summary

PayerBlue Cross Blue Shield - Wisconsin

PolicyHospital Clinic Visit facility reimbursement

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateNov 1, 2009

Next Review DateN/A

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.

Billing and Provider Instructions

Billing Rule

Professional provider billing instruction

Professional providers should report covered clinic services provided in a facility clinic setting on the professional CMS-1500 form with a place of service 'office'. Reimbursement to the professional provider includes professional services and associated overhead; the technical/overhead component is included in the professional provider's maximum allowable benefit. The facility may not bill the member or seek separate reimbursement from Blue Cross Blue Shield - Wisconsin for the technical or overhead component of these clinic charges.

Applies to all Plan products except Medicare Supplemental plans
Member held harmless for clinic overhead charges

Billing Rule

Billing restriction for facility clinic visit revenue codes

Facilities must not separately bill Blue Cross Blue Shield - Wisconsin on a UB-04 for facility clinic visits or services reported with revenue codes 510-525, 527-529 (and any successor codes), unless there is a contractual arrangement to provide specific disease management services using these revenue codes. In that limited instance, the facility must report the appropriate CPT/HCPCS code associated with the disease management service rendered. Professional providers reimbursed on the CMS-1500 with place of service office will have the technical and overhead component included in their payment; facilities may not seek additional reimbursement.

Revenue codes 510-525, 527-529 and any successor codes are affected
When a contractual disease management arrangement exists, report the related CPT/HCPCS code

OpenPayer

Hospital Clinic Visit facility reimbursement

Facility Clinic Visit Coverage Criteria

Relevant Codes and Status

Billing and Provider Instructions

Definitions

510-525	Facility UB-04 revenue codes referenced (not separately reimbursed unless contractual disease management arrangement exists)
527-529	Facility UB-04 revenue codes referenced (not separately reimbursed unless contractual disease management arrangement exists)