CurrentPremera BluecrossPolicy N/A

Facility Fees: Clinic Services, Professional Fees and Specialty Services - Treatment Room

Defines Premera Blue Cross plan limitations on clinic, freestanding clinic, treatment/observation room, and certain professional revenue codes when submitted on facility (UB-04/837I) inpatient and outpatient claims; applies to Premera and affiliated lines of business except where exceptions noted.

Policy Summary

PayerPremera Bluecross

PolicyFacility Fees: Clinic Services, Professional Fees and Specialty Services - Treatment Room

Policy CodePolicy N/A

Change TypeMaterial: Added effective-date non-reimbursement ruleclarified write-off consequence

Effective DateJuly 3, 2026 (rule effective for specified codes)

Next Review DateMar 12, 2026

Key ActionDo not submit listed clinic revenue codes on facility claims expecting reimbursement; submit treatment-room/professional revenue codes with an applicable CPT/HCPCS procedure code or expect provider write-off.

SourceLink

POLICY UPDATE CHANGES

Effective dates of service of July 3, 2026 and after: revenue codes 0760, 0769, and 0960 billed with any E/M CPT (99201-99499) or HCPCS clinic visit codes (G0438, G0439, G0463) on a facility claim will not be reimbursed unless submitted with an applicable specific CPT or HCPCS procedure code reflecting the actual treatment.

Revenue codes listed in the policy that meet the listed criteria are considered a provider write-off.

Alaska lines of business were re-added to the exceptions after having been removed in a prior update.

~20Revenue codes enumerated as non-reimbursed

3Rev codes impacted by new rule

99201-99499E/M CPT series referenced

G0438/G0439/G0463HCPCS clinic visit codes

YesProvider write-off

Coverage criteria and facility billing restrictions

Coverage criteria and restrictions

The Plan will not reimburse the following when billed on a facility claim unless the criteria below are met:

ALL of the following

0510 - Clinic - General
0511 - Clinic - Chronic Pain Center
0512 - Clinic - Dental Clinic
0513 - Clinic - Psychiatric Clinic
0514 - Clinic - OB/GYN Clinic

Policy Summary

PayerPremera Bluecross

PolicyFacility Fees: Clinic Services, Professional Fees and Specialty Services - Treatment Room

Policy CodePolicy N/A

Change TypeMaterial: Added effective-date non-reimbursement ruleclarified write-off consequence

Effective DateJuly 3, 2026 (rule effective for specified codes)

Next Review DateMar 12, 2026

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.

ALL of the following

0760 - Specialty Services - Treatment/Observation room: for dates of service on and after July 3, 2026, when submitted with any E/M CPT code (99201-99499) or HCPCS clinic visit codes (G0438, G0439, G0463) on a facility claim, these combinations will not be reimbursed. Services billed with 0760 should reflect the actual treatment or surgical procedure(s) rendered in the treatment room and should be submitted with an applicable specific CPT procedure code or HCPCS Level II code.
0769 - Other Treatment/Observation room: for dates of service on and after July 3, 2026, when submitted with any E/M CPT code (99201-99499) or HCPCS clinic visit codes (G0438, G0439, G0463) on a facility claim, these combinations will not be reimbursed. Services billed with 0769 should reflect the actual treatment or surgical procedure(s) rendered in the treatment room and should be submitted with an applicable specific CPT procedure code or HCPCS Level II code.
0960 - Professional Fees - General Classification: for dates of service on and after July 3, 2026, when submitted with any E/M CPT code (99201-99499) or HCPCS clinic visit codes (G0438, G0439, G0463) on a facility claim, these combinations will not be reimbursed.

Revenue and procedure codes and effective-date rule

Not reimbursed — Clinic revenue codesRevenueNot Covered

0510	Clinic - General
0511	Clinic - Chronic Pain Center
0512	Clinic - Dental Clinic
0513	Clinic - Psychiatric Clinic
0514	Clinic - OB/GYN Clinic
0515	Clinic - Pediatric Clinic
0516	Clinic - Urgent Care Clinic
0517	Clinic - Family Practice Clinic
0519	Clinic - Other Clinic

Not reimbursed — Freestanding clinic revenue codesRevenueNot Covered

0520	Freestanding Clinic - General
0521	Freestanding Clinic - Clinic visit by member to RHC/FQHC
0522	Freestanding Clinic - Home visit by RHC/FQHC practitioner
0523	Freestanding Clinic - Family Practice Clinic
0526	Freestanding Clinic - Urgent Care Clinic
0529	Freestanding Clinic - Other Freestanding Clinic

Not reimbursed — Preventive care revenue codesRevenueNot Covered

0770	Preventive Care Services - General
0771	Preventive Care Services - Vaccine Administration

Conditionally not reimbursed — Specialty/observation/professional when billed with E/M or specified HCPCS on facility claim (effective July 3, 2026 for some codes)RevenueNot Covered

0760	Specialty Services - Treatment/Observation room (see effective-date rule)
0761	Specialty Services - Treatment Room
0769	Other Treatment/Observation room (see effective-date rule)
0960	Professional Fees - General Classification (see effective-date rule)
0982	Professional Fees - Outpatient Clinic
0983	Professional Fees - Clinic

HCPCS clinic visit codes referencedHCPCS

G0438	Annual wellness visit, includes a personalized prevention plan of service (PPS), initial preventive physical examination; face-to-face visit, 60 minutes
G0439	Annual wellness visit, includes a personalized prevention plan of service (PPS), subsequent visit; face-to-face visit, 30 minutes
G0463	Hospital outpatient clinic visit for assessment and management of a patient

Effective date threshold — Services on or after July 3, 2026 subject to additional non-reimbursement rules for revenue codes 0760, 0769, and 0960 when billed with E/M CPT or specified HCPCS clinic visit codes

Effective date thresholdServices with dates of service on or after July 3, 2026: Revenue codes 0760, 0769, and 0960 submitted on a Facility (UB-04 / 837I) claim will be denied/not reimbursed when billed with any E/M CPT code (99201-99499) or HCPCS clinic visit codes G0438, G0439, or G0463.

General ruleWhen revenue codes 0760, 0761, 0769, 0960, 0982, or 0983 are billed on a Facility claim with any E/M CPT code (99201-99499) or HCPCS clinic visit codes G0438, G0439, or G0463, the revenue code charges are considered provider write-offs and will not be reimbursed unless provider contract or other exceptions apply.

Billing guidanceServices billed with revenue codes 0760, 0761, or 0769 should reflect the actual treatment or surgical procedure(s) rendered in the treatment room and should be submitted with an applicable specific CPT procedure code or HCPCS Level II code to reflect the services rendered.

Billing guidance and denial risk

Denial Risk

Billing/submission requirements and denial risk

Clinic charges submitted on a facility claim (UB-04 or 837I) using the revenue codes listed below will not be reimbursed by the Plan and are considered a provider write-off. Do not submit these clinic/facility revenue codes expecting reimbursement. In addition, certain revenue codes (0760, 0761, 0769, 0960, 0982, 0983) submitted on facility claims with any Evaluation & Management (E&M) CPT code (99201-99499) or HCPCS clinic visit codes (G0438, G0439, G0463) are not reimbursable unless the service is reported with an applicable specific CPT or HCPCS procedure code that reflects the actual treatment or surgical procedure performed in the treatment room. Exceptions may apply where a provider contract dictates or for Medicare Advantage/Medicare Supplement/Medicare Primary crossover facility claims.

Affected revenue codes (not reimbursed when billed on facility claim): 0510, 0511, 0512, 0513, 0514, 0515, 0516, 0517, 0519, 0520, 0521, 0522, 0523, 0526, 0529, 0770, 0771.
Revenue codes requiring specific CPT/HCPCS procedure codes to reflect treatment rendered (otherwise not reimbursed when billed with E&M or clinic visit codes on facility claims): 0760 (Specialty Services - Treatment/Observation Room) — effective on/after 2026-07-03 for listed criteria; 0761 (Specialty Services - Treatment Room); 0769 (Other Treatment/Observation Room) — effective on/after 2026-07-03 for listed criteria; 0960 (Professional Fees - General Classification) — effective on/after 2026-07-03 for listed criteria; 0982 (Professional Fees - Outpatient Clinic); 0983 (Professional Fees - Clinic).
Billing guidance: Do not submit the above clinic/facility revenue codes on facility claims expecting reimbursement; these may be denied or require write-off. When billing services that occurred in a treatment or observation room, report the actual treatment or surgical procedure with an applicable CPT or HCPCS Level II code rather than an E&M or general clinic visit code on the facility claim.
Denial risk: Claims billed on facility claim forms with the listed revenue codes and without an applicable specific procedure code (when required) are at risk for denial or will be considered a provider write-off.
Exceptions: Provider contracts may override this policy; Medicare Advantage, Medicare Supplement, and Medicare Primary crossover facility claims may follow different payment rules per contract or program requirements.

Definitions

Provider write-off

DefinitionRevenue codes listed and meeting the policy criteria are considered provider write-offs (not reimbursed by the Plan).

Examples of affected revenue codes0760, 0761, 0769, 0960, 0982, 0983

Condition for write-offCodes billed on a facility claim without an applicable specific CPT or HCPCS procedure code reflecting the actual treatment are not reimbursed and treated as provider write-offs.

Reference to exceptionsExceptions may apply for Medicare Advantage, Medicare Supplement, and Medicare Primary crossover facility claims or where provider contract dictates.

Facility claim

Claim form typesUB‑04 paper claim or 837I electronic format represent facility billing.

ApplicationClinic and professional revenue codes billed on these facility claim formats are subject to the policy's reimbursement restrictions.

AdjudicationFinal payment subject to claims adjudication edits and applicable provider scope of practice and fee schedule.