CurrentMass General Brigham Health PlanPolicy N/A

Provider Payment Guidelines — Outpatient Clinic Reimbursement

Guidelines for reimbursement of contracted providers for covered, medically necessary outpatient services performed in acute care hospital outpatient clinic settings; applies to Mass General Brigham Health Plan members and contracted providers.

Policy Summary

PayerMass General Brigham Health Plan

PolicyProvider Payment Guidelines — outpatient clinic reimbursement for E/M and related services

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateJan 1, 2025

Key ActionConsult the plan and provider contract to determine whether facility fees for E/M services are reimbursable or will be retracted.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

one E/MProfessional E/M allowed

not reimbursedFacility fee generally

AOH guidanceMassHealth methodology

2019-2025Publication history

E/M and Outpatient Clinic Coverage Rules

Policy Summary

PayerMass General Brigham Health Plan

PolicyProvider Payment Guidelines — outpatient clinic reimbursement for E/M and related services

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateJan 1, 2025

Key ActionConsult the plan and provider contract to determine whether facility fees for E/M services are reimbursable or will be retracted.

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.

Professional component: Mass General Brigham Health Plan reimburses the professional component of one Evaluation and Management (E/M) code per member, per date of service when performed in a hospital outpatient clinic setting.

Facility component

Facility component generally not reimbursed for E/M services performed in outpatient clinic settings; a separate facility fee will not be made to the hospital or to any other provider.
See revenue code guidance for exceptions.
Exception — outpatient mental health clinic: Professional and facility components are reimbursed when E/M services are performed in an outpatient mental health clinic.
Exception — contract/payment method dependency: Providers whose contracts stipulate OPPS or EAPG payment methods may receive facility reimbursement for certain clinic visit codes (for example, G0463 billed with revenue codes 510 or 770) as allowed by the contract.

Revenue code specifics and billing behavior: Certain revenue codes (e.g., 510-515, 519) indicate facility fees are not reimbursed separately for E/M services; revenue code 983 represents clinic professional component where E/M services are reimbursed, and the same E/M billed separately as a professional claim will be denied.

Revenue codes 761 and 770 note retraction when billed with Revenue Code 983 for the same E/M.

Billing conflicts and audits: E/M services billed with a non-clinic revenue code in conjunction with a bill for the clinic professional component of the same service are subject to post-payment audit and retraction; claims are subject to edits and medical record requests.

Non-E/M services and specialty clinics: Professional and facility components for non-E/M services in outpatient clinic settings may be reimbursed depending on provider contract and clinic type.

Member line-of-business and program guidance: For MassHealth and MGB ACO members, follow MassHealth Acute Outpatient Hospital guidance for reimbursement methodology; commercial and Medicare Advantage members follow the plan and provider contract terms.

Revenue and Billing Code Guidance

Revenue CodesRevenue

510	General Clinic Visit — Facility fees are not reimbursed separately for E/M services delivered in outpatient clinic settings.
511	Chronic pain center — Facility fees are not reimbursed separately for E/M services delivered in outpatient clinic settings.
512	Dental Clinic — Facility fees are not reimbursed separately for E/M services delivered in outpatient clinic settings.
513	Psychiatric clinic — Facility fees are not reimbursed separately for E/M services delivered in outpatient clinic settings.
514	OB/GYN clinic — Facility fees are not reimbursed separately for E/M services delivered in outpatient clinic settings.
515	Pediatric clinic — Facility fees are not reimbursed separately for E/M services delivered in outpatient clinic settings.
516	Urgent Care clinic — E/M services are not reimbursable.
517	Family practice clinic — E/M services are not reimbursable.
519	Other clinic — E/M services are not reimbursable.
761	Treatment Room — E/M services will be retracted as non-reimbursable clinic facility component when the same E/M is billed with Revenue Code 983.

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Referrals, Prior Authorization, and Provider Responsibilities

Prior Authorization

Referral and prior authorization required — verify per plan

Various services and procedures require referral and/or prior authorization. Providers must check the plan's referral and prior authorization requirements before providing services and obtain any required authorizations per the member's benefit plan and provider contract. Refer to the Plan's authorization resources (link/location referenced in policy) for specific service-level requirements.

Verify member benefit plan for referral requirements and member liability (copays, deductibles, coinsurance).
Obtain prior authorization when required before delivering the service to avoid denial or nonpayment.
Consult the plan's authorization resource referenced in the policy for procedure-specific prior authorization rules.

Definitions and Revenue Code Notes

Covered services and reimbursement

DefinitionCovered services are defined by the member's benefit plan and reimbursed according to the plan's network provider reimbursement or contracted rates.

Reimbursement basisThe manner in which covered services are reimbursed is determined by the Mass General Brigham Health Plan Payment Policy and by the provider's agreement with Mass General Brigham Health Plan.

Member liabilityMember liability amounts (copayments, deductibles, coinsurance) apply based on the member's benefit plan.

Claims processingClaims are subject to payment edits and audits; services considered incidental, integral, or part of a global allowance are not eligible for separate reimbursement.

Revenue codes and facility fee handling

Revenue code range510-519: Clinic visit revenue codes; multiple descriptors (e.g., 510 General Clinic, 513 Psychiatric clinic) where facility fees for E/M are generally not reimbursed separately.

Treatment room761: Treatment Room — E/M services will be retracted as non-reimbursable clinic facility component when the same E/M is billed with Revenue Code 983.

Preventive services770: Preventive Services — E/M services will be retracted as non-reimbursable clinic facility component when the same E/M is billed with Revenue Code 983; also used to bill G0463 with appropriate contracts.

Professional component code983: Professional component - Clinic — E/M services are reimbursed under this revenue code; if the same E/M service is billed separately as a professional claim, that separate claim will be denied.