CurrentPremera BluecrossPolicy CP.PP.419.v2.6

Contract Exclusions/Disallowed Charges - Inpatient and Outpatient Facility Services

Defines inpatient and outpatient facility charges that are not separately reimbursable by Premera Blue Cross and affiliated plans; applies to facility claims (UB-04/837I) and affects facility providers submitting hospital/facility claims.

Policy Summary

PayerPremera Bluecross

PolicyContract Exclusions/Disallowed Charges - Inpatient and Outpatient Facility Services

Policy CodePolicy CP.PP.419.v2.6

Change TypeClarifications and added examples (non-material)

Effective Date

Next Review Date

Key ActionEnsure facility claims do not bill charges considered included in room and board (examples listed) and limit venipuncture (36415) to one per day when applicable.

SourceLink

POLICY UPDATE CHANGES

Added additional examples to contrast materials in the Radiology category and additional IV fluid examples in the Pharmacy category.

Added clarifying statement for observation charges under room and board category.

Added cross-reference policies for several related facility topics (e.g., Critical Care in ED when discharged to home; Emergency Department E/M Level of Service).

multiplecategories listed

1/dayvenipuncture allowance

applies tolines of business

03/01/2020effective reference date

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.

Non-Reimbursable Facility Charges

Non-reimbursable facility charges (examples)

The Plan does not reimburse the following facility charges as separate line items; they are considered included in room & board or part of another service. The list is illustrative and not exhaustive.

Blood and Blood Product Administration

Administrative costs for processing and storage of blood not separately reimbursable
Blood administration/transfusions and monitoring not separately reimbursable
Documentation and preparation of blood products included

Nursing care and treatment

Admission assessment included
Bedside nursing care (RN/LPN/CNA), nursing/tech time, incremental nursing (1:1) and ICU/CCU nursing included
Bladder scans and dietary related nursing services included
Hemodynamic monitoring and monitoring of patients included
IV starts, IV administration, IV push, IV flush (e.g., Heparin), assessments, dressing changes, infusion of fluids included
Medication administration including vaccines, subcutaneous and intramuscular included
Minor medical/surgical supplies and point-of-care/bedside testing (e.g., blood count, ABG, clotting time, glucose monitoring, urine dipsticks, H/H) included
Nasogastric tube insertions, PICC line insertion, tracheostomy care, urinary catheterization included
Observation and outpatient services billed on same date as inpatient room & board considered included
One venipuncture (36415) charge per day allowed (exception)

Equipment required as component of level of care

Arterial and Swan Ganz monitors in ICU/CCU, NICU, OR, Recovery Room included
Cardiac monitors in ICU/CCU, NICU telemetry/step down, OR and Recovery Room included
CO2 end tidal monitors for patients on ventilator and in OR included
Fetal monitors in labor room included
Fluoroscopy/ultrasound/vascular access guidance for procedures included
Oximetry monitors and oxygen per day/hour when confined to special care unit included

Equipment as component of service/procedure

Anesthesia machines, cameras, C-Arm/fluoroscopy, scopes, surgical instruments included
Robotic surgical systems and computer-aided navigation systems (e.g., DaVinci) included
Drills/saws/blades used in OR, perfusion equipment when billed with perfusionist time, feeding pumps, IV pumps/PCA pumps included
Batteries, thermometers, microscopes, neurological monitors, grounding pads and similar items included

Operating Room / Surgical Suite

Use of the operating room, OR set-up charges and equipment (linen packs, scopes, sterile instruments, special/custom surgical tools and instrument packs/trays) included
Post‑op dressings, supplies (sutures, gloves, bandages, sponges, prep kits, drapes, IV sets, closure devices, tubing) included
Robotic systems and computer‑aided navigation systems included
Services of qualified facility-employed professional and technical personnel included
After hours/callback not separately reimbursable if facility has 24‑hour coverage

Medical / Surgical Supplies

All OTC items and supplies that may be purchased over the counter not separately reimbursable
All reusable items, supplies and equipment provided to all patients in a treatment area or receiving the same service not separately reimbursable
Supplies integral to a specific service/location (e.g., catheter guidewires, Foley catheters, irrigation supplies, syringes, telemetry batteries, wall suction, wipes, swabs, bed pans) included

Respiratory Services

PEEP/CPAP/O2 when patient is on ventilator support included
Pulmonary services (nebulizers, chest physiotherapy, swallow testing, IPPB therapy, nebulizer treatments) included
Ventilatory support management, weaning and extubation included
After hours/callback not separately reimbursable if facility has 24‑hour coverage

Radiology

Contrast materials (e.g., Gadoteridol, LOCM, Gastrogafen, Gadoterate, Indigo Carmine, Indocyanine Green, Iohexol, Isosulfan Blue, oral contrast) included
Fluoroscopy/ultrasound/vascular access guidance for procedures included
Radiopharmaceuticals (e.g., Technetium Tc‑99m) included
Services of qualified facility-employed professional and technical personnel included
Blood draws from capillary puncture, arterial or vascular devices and point-of-care testing included

Emergency Room

All monitoring, equipment, supplies, time, and staff charges included
IV starts, IV administration, IV push, IV flush and assessments, dressing changes, infusion of fluids included

Pharmacy

Administration, documentation, and preparation of drugs in an inpatient setting included
Anesthetic products related to anesthesia maintenance, anesthesia for surgical procedures and reversal agents included
Materials necessary for preparation/administration of drugs (small volume fluids/diluents, Normal Saline, Dextrose, sterile water, Heparin flushes, etc.) included
Radiopharmaceuticals and services rendered by pharmacists and pharmacy personnel (mixing fees, checking/restocking) included

Other

Personal care items and patient convenience items (e.g., deodorant, soap, TV, telephone, pillows, toothbrush/toothpaste) not separately reimbursable
Transportation fees related to specimen pickups/handling fees included (radiology/lab context)

Policy enforcement and exceptions

Violations may result in increased auditing, monitoring, performance guarantee penalties, and/or contract termination
Exceptions may be made where a provider or employer group contract dictates otherwise

Claim Form, Coding Context, and Exceptions

Claim form and adjudication contextmixed

No codes listed

Venipuncture allowance (36415)

Policy allowanceOne venipuncture (CPT 36415) charge allowed per patient per day

ContextException noted within Nursing and Lab sections where venipuncture is otherwise considered included in room & board or other services

Claim implicationOnly a single 36415 line may be reimbursed on a facility claim for the same member/date; additional venipuncture charges are considered included and not separately reimbursable

Adjudication Rules and Provider Reimbursement Limits

Billing Rule

Coverage adjudication and provider reimbursement limits

Coverage and payment for any service are determined by the member's eligibility, applicable benefit limits, and the Plan's Medical Policy; final payment is subject to industry and Plan claims-adjudication edits. Reimbursement is limited to services within the provider's scope of practice and the fee schedule applicable to that provider. Facility charges listed in this policy may be denied in pre-payment or post-payment audit review when they are considered included in room & board or part of another service.

Coverage determined by member eligibility, benefit limits, and Plan Medical Policy.
Final payment subject to claims-adjudication edits and Plan coding policies.
Reimbursement restricted to provider scope of practice and applicable fee schedule.
Listed facility charges may be identified and denied in pre-payment or post-payment hospital claim audits as not separately reimbursable.

Definitions — Charges Included in Room and Board

Charges considered included in room & board or another service

DefinitionCharges that are intrinsically and/or customarily included in room and board or as part of another procedure or service (not separately reimbursable)

Examples — Nursing & TreatmentAdmission assessment; bedside nursing (RN/LPN/CNA) care; IV starts/administration/flushes; medication administration; observation services billed same date as inpatient room & board; PICC line insertion; point-of-care/bedside testing

Examples — Equipment as component of level of careArterial/Swan Ganz monitors; cardiac monitors (ICU/CCU/NICU/OR/Recovery); CO2 end tidal monitors for ventilated patients; fetal monitors; oximetry; oxygen per day/hour when confined to special care unit

Examples — Supplies/Procedure ComponentsSmall volume fluids used as diluent to mix a drug; syringes, Foley catheters, telemetry batteries, wall suction, feeding pumps, IV tubing and sets, PCA pumps

Examples — Radiology, Lab, PharmacyFacility-employed professional/technical personnel services; contrast materials and radiopharmaceuticals; lab and pharmacy preparation/documentation services (these are included, with the single venipuncture/day exception in Lab)