CurrentHumanaPolicy CP2022008

Outpatient Claim Itemized Bill Review

This policy governs Humana's review of outpatient facility itemized bills (UB-04/CMS-1450 and electronic equivalent) to verify that billed revenue codes correspond to appropriately billed items, supplies, and services for Medicare Advantage, Commercial and Medicaid products. It affects outpatient facilities including hospital outpatient departments and ambulatory surgery centers billing Humana.

Policy Summary

PayerHumana

PolicyOutpatient Claim Itemized Bill Review

Policy CodePolicy CP2022008

Change TypeNo material changes

Effective Date02/2023

Next Review Date

Key ActionProvide an itemized bill on request and follow customary charging practices when separately billing items, supplies and services.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

Medicare Advantage, Commercial and MedicaidProducts to which this policy applies

CP2022008Policy number

UB-04 / CMS-1450 and 837IClaim forms covered

Examples listedTypical non-separately billable items

Separate Billing and Coverage Criteria

Separate billing criteria for outpatient items/supplies/services

Humana generally does not separately pay for items, supplies and services that are routine or included in other outpatient charges; Medicaid reviews follow applicable state agency requirements.

ALL of the following

Examples
- Bandages
- IV flushing
- Dressing changes
- Equipment monitoring

Policy Summary

PayerHumana

PolicyOutpatient Claim Itemized Bill Review

Policy CodePolicy CP2022008

Change TypeNo material changes

Effective Date02/2023

Next Review Date

Key ActionProvide an itemized bill on request and follow customary charging practices when separately billing items, supplies and services.

SourceLink

On This Page

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Itemized Bill Requests and Claim Requirements

Billing Rule

Itemized Bill Request and Customary Charging Practices

Humana may request an itemized bill for an outpatient facility claim (UB-04/CMS-1450 or 837I) to verify that billed revenue codes represent charges for appropriately billed items, supplies and services. Revenue codes are categorical and do not describe specific items; providers must follow customary charging practices and should not separately bill routine items already included in other outpatient charges. Humana sometimes reviews itemized bills to determine whether supplies, items and services are separately billable.

A provider must consistently follow its customary charging practices for all Medicare and non‑Medicare patients and for all payers/health plans.
Humana may request an itemized bill for outpatient encounters to determine if items listed are separately billable.
Routine items and supplies included with a primary service should not be billed separately.

Denial Risk

General Claim Requirements

Claims payments are subject to plan requirements beyond this policy, including medical necessity, reasonableness, and any applicable referral or authorization requirements. This policy applies to outpatient facilities such as hospital outpatient departments and ambulatory surgery centers. The following examples are typically not separately billable and therefore not separately payable from the primary service charge(s): bandages; IV flushing; dressing changes; equipment monitoring; routine nursing care and assessments; over‑the‑counter personal care items (ice packs, alcohol wipes, cotton balls); and reusable items or equipment routinely provided to all patients during an outpatient encounter (for example, cardiac monitors or DME items used while in the facility).

Claims remain subject to applicable referral and prior authorization requirements.
The policy scope includes hospital outpatient departments and ambulatory surgery centers.
Examples listed are not exhaustive; providers should apply customary charging practices when determining billable items.

Key Definitions

Customary charging practices

DefinitionCustomary charging practices: A provider's common or established practice for classifying a particular item or service that is consistently followed for all patients and does not result in an inequitable apportionment of cost to the Medicare Program.

ApplicationUsed to determine whether outpatient items, supplies and services are separately billable or are included in facility charges.

ScopeApplies to all patients and payers; Humana expects providers to follow these practices when submitting separate charges.

Medicaid noteFor Humana Medicaid plans, itemized bill review follows applicable state Medicaid agency requirements (see coverage criteria).

Related actionHumana may request an itemized bill to verify that billed revenue codes correspond to appropriately billed items, supplies and services and that customary charging practices were followed.

OpenPayer

Outpatient Claim Itemized Bill Review

Separate Billing and Coverage Criteria

Revenue Codes

Itemized Bill Requests and Claim Requirements

Key Definitions