CurrentColorado Rocky Mountain Health PlansPolicy N/A

Hospital inclusive charges (bundled room/board and facility supplies)

Defines which items, supplies, equipment and routine services are considered included in hospital room and board, facility or ancillary charges and therefore not separately reimbursable for UnitedHealthcare Community Plan Medicaid products billed on UB-04 forms.

Policy Summary

PayerColorado Rocky Mountain Health Plans

PolicyHospital inclusive charges (bundled room/board and facility supplies)

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionProviders must submit accurate claims and may receive documentation requests, itemized bill reviews and hospital bill audits to ensure compliance with this policy.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

UB-04claim form scope

7+ groupsrevenue code examples listed

1 unit/dayventilator/CPAP rule

12/01/2024policy start

01/23/2024last review

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.

Included (Bundled) Items and Services — Not Separately Reimbursable

Bundled items and services (not separately reimbursable)

Items, services and staff activities that are included in the room and board, facility or ancillary charges and are not eligible for separate reimbursement:

Routine supplies and equipment (floor stock)
- Sterile and non-sterile medical/surgical supplies normally stocked by the facility (examples include sterile surgical instruments, biopsy forceps; non-sterile supplies such as stethoscopes, bandages, diagnostic kits, medical instruments; alcohol swabs/pads; bandages/dressings; batteries; bedpans; cold/hot packs; thermometers; IV solutions; tubing; specimen collection kits).
- Medical equipment and supplies generally available to all patients and incorporated into facility or procedure reimbursement (examples include perfusion equipment and supplies; pumps such as IV, syringe, blood warmer, suction, feeding, PCA; beds, commodes, scales; fetal monitors).
Clinical services and nursing activities
- Nursing care and services carried out by bedside nurses (RN/LPN), respiratory therapists, certified nursing assistants, perfusionists or other technicians as part of daily responsibilities (including administration of blood/products, medication administration, IV fluids, assisting physician with procedures, medical record documentation, accessing indwelling IV catheters, preparing/dispensing medication, monitoring vital signs and cardiac monitors, fluid/specimen collection, personal hygiene, point-of-care testing, respiratory treatments, insertion/removal/maintenance of nasogastric tubes, maintenance or flushing of tubing, tracheostomy care, urinary catheterization, venipuncture, IV and PICC line insertions, IV transfusions).
Surgical, procedural and facility charges
- Charges for surgical suites, treatment rooms, endoscopy labs, cardiac cath labs, X-ray facilities, pulmonary and cardiology procedural rooms and related surgical/perioperative services include the full range of nursing personnel services, supplies, and equipment; routine components are not separately reimbursable (examples include anesthesia equipment, monitors and gases; intubation/extubation supplies; blood pressure/vital sign equipment; cardiac monitors; cardiopulmonary bypass equipment; surgeons' loupes; grounding pads; laparoscopes/bronchoscopes/endoscopes and accessories; laboratory specimen collection equipment).
Respiratory care and ventilator/CPAP
- Facility-owned ventilator or CPAP charges: reimbursement will be considered for one (1) unit per day; routine components and activities integral to delivery of ventilator/CPAP care are bundled and not separately reimbursed (examples of non-separately reimbursed components include system set up, system checks, circuit changes, respiratory assessment, carbon dioxide end tidal setup/monitoring, endotracheal suctioning, weaning, extubating).
  One ventilator/CPAP unit reimbursable per day.
IV therapy and pharmacy services
- Intravenous therapy, IV infusion pumps, IV pharmacy services and related supplies when incorporated into revenue code groupings are included in bundled facility/procedure reimbursement (examples include IV pumps, IV saline/heparin flushes, IV tubing).
Coding examples
- Examples of revenue code groups referenced for bundled supplies, equipment and rooms include revenue codes 250-279, 300-370, and codes such as 410, 412, 419, 460; specific items referenced in the policy are associated with these revenue code groups.

UnitedHealthcare Community Plan applies CMS guidelines and industry coding sources to identify routine services and items that are included in the room and board, facility charge, or ancillary service charge and therefore are not separately reimbursable.

Revenue Codes, Coding Examples and Unit Limits

Medical/Surgical Supplies (Revenue)Revenue

250	Medical/Surgical Supplies - general
260	IV Therapy/Infusion supplies
261	IV infusion pump supplies
262	IV pharmacy services supplies
263	Perfusion equipment and supplies
264	Pumps (IV, syringe, PCA)
265	Beds, commodes, scales, overhead frame
266	Fetal monitors
267	Sterile supplies (surgical instruments, biopsy forceps, implanted devices)
268	Non-sterile supplies (bandages, diagnostic kits)

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Surgical/Operating Room Supplies (Revenue)Revenue

300	Anesthesia equipment and monitors - OR
301	Robotic assisted technique accessories
310	Intubation/extubation supplies
320	Blood pressure/vital sign equipment supplies
330	Cardiac monitor supplies
340	Cardiopulmonary bypass supplies
350	Surgeons' loupes/visual assisting devices supplies
360	Grounding pads and hemochron supplies
370	Video camera equipment and imaging accessories

Respiratory & Ventilator-related Supplies (Revenue)Revenue

410	Respiratory assessment and related supplies
412	Tracheostomy supplies and care
419	CO2 end tidal system setup/monitoring
460	Endotracheal suctioning, weaning, extubating components

Other Facility-owned Durable Equipment (Revenue)Revenue

419	Also used for monitoring and setup components (duplicate listing for emphasis)
460	Additional respiratory/ventilator adjunct supplies

Note - State Exceptionsmixed

CO	Colorado - exempt from this policy
HI	Hawaii - special billing using Occurrence Codes 74-76 for certain services
KY	Kentucky - exempt from this policy
MD	Maryland - exempt from this policy
MN	Minnesota - exempt from this policy
MS	Mississippi - exempt from this policy
MO	Missouri - exempt from this policy
NE	Nebraska - exempt from this policy
NM	New Mexico - exempt from this policy
NC	North Carolina - exempt from this policy

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ventilator_unit_limit — 1 unit/day reimbursement rule

Ventilator/CPAP unit limitCharges for facility-owned ventilator or CPAP will be considered for reimbursement for one (1) unit per day.

Claims Submission, Documentation and Audit Expectations

Documentation Required

Claims submission and documentation — provider obligations and audits

You are responsible for submission of accurate claims. Providers may receive documentation requests, itemized bill reviews and hospital bill audits to verify that charges billed on UB‑04 forms reflect services eligible for separate reimbursement and to confirm bundled items are not billed separately.

Submit accurate claims using codes that correctly describe the services provided on UB‑04 forms.
Respond to documentation requests and provide itemized bills when requested.
Cooperate with hospital bill audits and reviews that verify bundled room/board, facility or ancillary charges.

Definitions — Routine Services, Equipment and Supplies

routine services

DefinitionRoutine services are those incorporated into the room/observation room, facility, or ancillary service charge and are not eligible for separate reimbursement.

Examples includedRegular room costs, dietary services, nursing services, minor medical and surgical supplies, medical and psychiatric social services, and use of certain equipment and facilities without a separate charge.

Reimbursement applicationRoutine aspects of ancillary services will not be separately reimbursed even when the broader ancillary service may be reimbursable.

routine medical equipment and supplies

DefinitionFloor stock / routine medical equipment and supplies are items generally available to all patients and incorporated into the overall reimbursement for a procedure, room and board, or facility charge; they are not separately reimbursable.