Transparency Policy: Place of Service Mismatch
This policy governs prepayment claim edits that deny procedure codes billed with an inappropriate place of service for professional and outpatient facility claims; it applies to providers submitting claims to the health plan that adopted this policy.
No material clinical or coverage changes in this revision.
Place of Service Mismatch — Coverage Criteria
Place of Service Mismatch — Coverage Criteria
Services billed with a place of service (POS) that does not align with CPT/HCPCS descriptions or CMS/state guidelines are subject to prepayment edits and denial. The following criteria define when place-of-service mismatch edits apply.
ALL of the following
- The procedure code is governed by CPT or HCPCS descriptions or guidelines that specify or imply an appropriate place of service (e.g., inpatient, outpatient, office, home, ASC).
Sources: AMA CPT manual, CMS, and state guidance considered.
- The claim's reported Place of Service (POS) does not match the POS indicated by the CPT/HCPCS code description or guidance for that service.
Mismatch includes situations where the CPT/HCPCS descriptor explicitly limits performance to a specific setting or where professional guidance indicates a typical or required setting.
- The claim is subject to prepayment claim edits applied by code auditing software configured to enforce POS alignment for CPT/HCPCS codes.
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