Unbundling Adjustments on Clean Claim Reviews
Defines how Fidelis Care evaluates facility-billed supply and service charges for unbundling during clean claim reviews and which items are not separately reimbursable; applies to institutional providers and all product types.
No material clinical or coverage changes in this revision.
Unbundling Criteria and Exclusions
Unbundling criteria and exclusions
Criteria used to determine whether a supply or service is separately payable:
ALL of the following
- Medical necessity: supply/service must be medically necessary and reasonable for the diagnosis or treatment of illness or injury or to improve functioning.
- Physician order: supply/service must be furnished at the direction of a physician by distinct physician order.
Not separately payable when any of the following apply:
- Supplies that are generally available to all patients billed at the same underlying room and board acuity level or ordinarily furnished during the course of a procedure (cost included in room/procedure charge).
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