CurrentOscar HealthPolicy N/A

Hospital Based Clinics reimbursement

Governs reimbursement for professional and facility claims for services delivered in hospital-based clinic settings for Oscar Health members; affects professional providers and hospital/institutional facilities billing Oscar.

Policy Summary

PayerOscar Health

PolicyHospital Based Clinics reimbursement

Policy CodePolicy N/A

Change TypeClarified and added reimbursement guidelines

Effective DateN/A

Next Review Date2026-01

Key ActionBill covered hospital-based clinic professional services on a CMS 1500 with place of service 'office'; facilities should not bill UB-04 revenue codes 510-519 or 520-529 for separate reimbursement.

SourceLink

POLICY UPDATE CHANGES

Added description section.

Clarified Policy section regarding reimbursement for professional providers and facility billing rules.

Added Reimbursement Guidelines section.

Deleted Coding section.

Updated guidelines for when G0463 is considered a non-reimbursable service.

510-519;520-529revenue codes not reimbursed

10004-69999;90281-90756;90935-98943;99100-99199code ranges permitting facility reimbursement

G0463;99202-99215service codes referenced

01/30/2025last review

Coverage Criteria for Hospital-Based Clinic Services

Coverage criteria for hospital based clinic services

Covered when ALL of the following are met:

ALL of the following

Services are reported on a professional CMS 1500 form with place of service 'office'.
Oscar reimburses the professional provider for covered services and associated overhead/technical components when billed on the CMS 1500; the professional payment includes clinic overhead and technical component.

ALL of the following

ANY of the following
- Revenue codes 510-519

Policy Summary

PayerOscar Health

PolicyHospital Based Clinics reimbursement

Policy CodePolicy N/A

Change TypeClarified and added reimbursement guidelines

Effective DateN/A

Next Review Date2026-01

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.

Billing and Prior Authorization Actions

Billing Rule

Billing and Prior Authorization Required Actions for Hospital-Based Clinic Visits

Provider billing and prior authorization actions for hospital-based clinic visits: Hospital-based clinic visits should be billed by the professional provider on a professional CMS 1500 form with Place of Service = Office. Do NOT bill the facility separately on a UB-04 for clinic visit professional services when revenue codes 510-519 or 520-529 (and any successor revenue codes) are present — the technical/overhead component is included in the professional provider payment and the member is held harmless. If services are billed on a UB-04, reimbursement to the facility will only be considered when the claim contains one or more allowable medical/surgical codes in the ranges listed below. Document the location (hospital-based clinic), place of service, and the specific codes billed on the CMS 1500 or UB-04 as applicable to support correct payment and avoid denials.

Bill professional clinic visits on CMS 1500 with Place of Service = Office when services are provided by a professional provider in a hospital-based clinic.
Do not submit a separate UB-04 facility claim for clinic visit professional services when revenue codes 510-519 or 520-529 are present; facility technical/overhead is included in the professional payment.
If submitting a UB-04 for facility reimbursement, include one or more codes within these ranges to be considered: 10004-69999, 90281-90756, 90935-98943, 99100-99199.
Ensure documentation supports site of service and that the professional provider reported the E/M or other service on the CMS 1500; maintain medical record evidence to justify any UB-04 facility charges.
Member is held harmless for clinic overhead charges billed by the facility when professional billing is properly submitted.

OpenPayer

Hospital Based Clinics reimbursement

Coverage Criteria for Hospital-Based Clinic Services

Service Codes and Code Ranges

Billing and Prior Authorization Actions

Definitions

G0463	Hospital outpatient clinic visit (non-physician practitioner)
99202-99215	Office/outpatient evaluation and management codes

10004-69999	Medical/surgical procedure code range
90281-90756	Immunization codes range
90935-98943	Therapeutic, respiratory, dialysis and other procedure codes
99100-99199	Anesthesia add-on codes