CurrentEmblemHealthPolicy N/A

Routine Supplies & Services - Not Separately Reimbursable in the Inpatient Hospital Setting

Governs what routine supplies, equipment and services are considered included in inpatient room, procedure or operating room charges and therefore not separately reimbursable to facilities; applies to inpatient acute care facilities billing the EmblemHealth plan.

Policy Summary

PayerEmblemHealth

PolicyRoutine Supplies & Services - Not Separately Reimbursable in the Inpatient Hospital Setting

Policy CodePolicy N/A

Change TypeNo material change

Effective DateJan 1, 2020

Next Review DateN/A

Key ActionDo not bill separately for routine inpatient supplies/services that meet criteria; ensure supplies/services are physician-ordered and medically necessary.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

multiplelists of non-separately reimbursable supplies, equipment and services

CMS HACfollows CMS HAC guidance

OR inclusiveoperating room inclusive

single-sample rulelab billing rule

Non-Separately Reimbursable Criteria

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.

Non-separately reimbursable criteria and examples

Covered when ALL of the following are met:

Supply/service is medically necessary and reasonable for diagnosis, treatment, or improvement of function

Supply/service is furnished at the direction of a physician (by distinct physician order)

Supply/service is included in the underlying room, procedure, or operating room charge when it is generally available to all patients billed the same acuity/procedure level or is necessary/integral to provision of a specific underlying service

Items that may be purchased over-the-counter, reusable items, or supplies for which use does not result in an incremental cost are not separately reimbursable

All charges are subject to review to confirm amounts billed reasonably and consistently relate to underlying direct and indirect costs

Non-reimbursable supplies and equipment (examples)

Thermometers, temperature probes
Pacing cables/wires/probes; pressure/pump transducers; transducer kits/packs
SCD sleeves/compression sleeves/TED hose; oximeter sensors/probes/covers; electrodes and electrode cables/wires
Foley/straight catheters, urometers/leg bags/tubing; specimen traps/containers/kits
Syringes, needles, lancets, butterflies; IV supplies and tubing, extensions, angio-caths, start kits, pressure bags, adapters, caps, plugs, fluid warmers, sets, transducers
Dressing change trays/packs/kits; dressings, gauze, sponges, Kerlix, Tegaderm, OpSite, Telfa; skin cleansers/preps; irrigation solutions; irrigants

Non-reimbursable services (examples)

Patient transport; transport fees
IV infusion/IV push; medication preparation; IV or PICC line insertions
Separate nursing charges; facility personnel charges (lactation, dietary consultants, professional therapy functions)
Venipuncture, specimen collection, draw fees, phlebotomy, heel stick
Point-of-care monitoring and testing (bedside glucose, oximetry, fecal occult blood) and monitoring such as pulse oximetry, telemetry except in med/surg room, blood pressure, capnography, end tidal CO2
Education/training; preparation or set-up charges; RT assessment; bladder scans; sputum induction

Operating room and procedure charges include use of the operating room, qualified professional and technical personnel, linen packs, basic instrument packs, routine supplies (sutures, gloves, dressings, sponges, prep kits, drapes, surgical attire) and robotic technology and are not separately reimbursable

Pharmacy charges include drug cost, administration, preparation materials and pharmacy personnel services and are not separately reimbursable

Blood, blood products and administration services (including thawing/pooling fees) are not separately reimbursable on inpatient claims

CMS Hospital Acquired Conditions (HACs): when a HAC occurs, facilities must identify and remove charges and/or days directly resulting from the HAC from the claim prior to submission

Lab billing: Plan will reimburse for each blood sample analysis performed; multiple charges for results obtained from the same underlying blood sample analysis are not separately reimbursed

Daily or one-time supply fees/items that are unidentified or unsupported by medical records/documentation are not reimbursable

Inpatient Bundled Items, Medically Necessary Requirement, and Coding Notes

Inpatient bundled items and servicesmixedCovered

Operating room charge includes instruments, basic packs and robotic technology; blood/blood product administration not separately reimbursable; thawing/pooling fees not separately reimbursable; Pharmacy charges include drug costs and administration/materials/services; daily or one-time unidentified supply fees not reimbursable; IV pumps, PCA pumps, specialty beds, bair hugger machines/blankets, wound vacuum pumps, oximeter monitors, suction pumps, breast pumps not separately reimbursable; multiple charges for results from the same underlying blood sample analysis are not separately reimbursed; Plan follows CMS Hospital Acquired Conditions (HAC) guidance requiring removal of HAC-related charges/days from claims.

Medically necessary and physician-ordered requirement

RequirementSupply or service must be medically necessary, reasonable for the diagnosis or treatment, and furnished at the direction of a physician (by distinct physician order).

Included criteriaSupplies generally available to all patients billed the same room/acuity level or procedure are not separately payable; cost is included in underlying charge.

Integral itemsItems necessary or integral to provision of a specific underlying service are not separately payable.

Reusable itemsCharges for reusable items, supplies and equipment are not separately payable because use does not result in incremental cost.

Over‑the‑counter itemsItems that may be purchased over the counter are not separately payable.

Billing and Claim Submission Expectations

Billing Rule

Billing and claim submission expectations

Do not bill separately for routine inpatient supplies, equipment or services that meet the policy criteria; these costs are considered included in the underlying room, procedure or operating room charges. Ensure each supply or service is medically necessary and furnished at the direction of a physician (by distinct physician order) before seeking separate reimbursement. Identify and remove charges/days directly resulting from CMS-defined Hospital Acquired Conditions (HACs) from inpatient claims prior to submission.

Supplies/services must be medically necessary and furnished at direction of a physician (distinct physician order).
Supplies generally available to all patients billed the same acuity/procedure level are not separately payable.
Operating room charges (instruments, basic packs, routine supplies, robotic technology) and blood/blood product administration (including thawing/pooling fees) are not separately reimbursable.
Charges/days directly resulting from CMS HACs must be identified and removed from inpatient claims before submission.

Key Definitions

Routine supplies and services

DefinitionSupplies or services that are integral components of underlying room and/or procedure charges (generally available to all patients billed the same acuity level or necessary/integral to provision of a specific underlying service).

Operating room inclusionsOperating room charge includes use of the room, qualified personnel, linen/basic instrument packs, dressings, sutures, gloves, sponges, prep kits, drapes, surgical attire and robotic technology; these are not separately reimbursable.

Daily/one‑time feesDaily supply or one‑time supply fees that are unidentified or unsupported by medical records are not reimbursable.

Hospital Acquired Conditions (HACs)

DefinitionHospital Acquired Conditions (HACs) are conditions recognized by CMS for which the Plan follows current and future CMS recognition.

POA indicator requirementCurrent and valid Present on Admission (POA) indicators (as defined by CMS) must be populated on all inpatient acute care Facility Claims.

Claim adjustmentWhen a HAC occurs, facilities must identify charges and/or days directly resulting from the HAC and remove those charges/days from the claim prior to submission; such charges/days shall not be billed to the Plan or the Member.