CurrentPremera BluecrossPolicy CP.PP.419.v2.5

Contract Exclusions/Disallowed Charges - Inpatient and Outpatient Facility Services

Defines inpatient and outpatient facility charges that Premera Blue Cross considers not separately reimbursable when billed on UB-04/CMS-1450 or 837I; applies to Premera and affiliated lines of business and products.

Policy Summary

PayerPremera Bluecross

PolicyContract Exclusions/Disallowed Charges - Inpatient and Outpatient Facility Services

Policy CodePolicy CP.PP.419.v2.5

Change TypeEditorial updates and content clarifications (non‑material)

Effective Dateas written

Next Review Date

Key ActionSubmit facility claims on UB-04/CMS-1450 or 837I; claim audits (pre- or post-payment) will identify non-reimbursable services.

SourceLink

POLICY UPDATE CHANGES

Two Payment Policies added to the Cross Reference section.

Alphabetized sub-bullets in Policy section and added/modified bullets across Nursing, Equipment, and Operating Room sections (e.g., added bedside nursing care, tracheostomy care, robotic systems, surgical instruments).

Pharmacy Services bullets revised to add anesthetic products related to anesthesia maintenance and reversal agents and to remove prior reference to propofol example.

Clarified nursing, respiratory, radiology and pharmacy non-reimbursable items across several updates (2020–2025), including allowance of one venipuncture (36415) per day.

CP.PP.419.v2.5internal identifier

2025-04-07last approval

One/day

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Non-reimbursable Facility Services

Non-reimbursable Facility Services (selected examples)

The Plan will not reimburse separately for the following facility services as they are considered intrinsic to room/board or a primary procedure:

ALL of the following

Blood and blood product administration
- Administrative costs for processing and storage of blood
- Blood administration/transfusions and monitoring of patient
- Documentation and preparation of blood products
Nursing care and related services
- Admission assessment
- Bedside nursing care carried out by Nurses (RN/LPN) and Certified Nursing Assistants
- Dietary and related nursing services and dietary services
- Hemodynamic monitoring and monitoring of patients
- Incremental nursing - 1:1 and ICU/CCU setting
- IV starts, IV administration, IV push, IV flush (e.g., Heparin), assessments, dressing changes, infusion of fluids
- Medication administration including vaccines, subcutaneous and intramuscular
- Nasogastric tube insertions
- PICC line insertion
- Tracheostomy care
- Urinary catheterization
- Notwithstanding the foregoing, one venipuncture (CPT 36415) charge per day allowed
  Exception: one venipuncture (36415) allowed per day
Equipment considered component of specific level of care or service
- Arterial and Swan Ganz monitors in ICU/CCU, NICU, Operating Room and Recovery Room
- Cardiac monitors in ICU/CCU, NICU Telemetry or Step Down, Operating Room and Recovery Room
- CO2 End Tidal Monitor for patients on ventilator and in Operating Room
- Fetal monitors in labor room setting
- Oximetry monitors
- Fluoroscopy/Ultrasound/Vascular access guidance for procedures
Operating room / surgical suite charges and supplies
- Use of the operating room and operating room set-up charges and equipment
- After hours/call back if the facility has 24-hour coverage
- Linen packs, scopes, sterile instruments, special/custom surgical tools and instrument packs and trays used as part of surgical procedures
- Post-op dressings, equipment and sterile supplies (e.g., sutures, gloves, bandages/dressings, sponges, prep kits, drapes, surgical attire, Ambu Bags, PICC lines, irrigation lines, skin staplers, skin adhesive, burrs, packing, needles, IV sets, closure devices and tubing)
- Personal care items used for patient convenience and items directly resulting from a procedure or test (e.g., deodorant, dry bath, lotion, mouthwash, telephone calls, television, pillows, etc.)
Medical/surgical supplies and consumables
- All items and supplies that may be purchased over the counter (OTC)
- All reusable items, supplies and equipment provided to all patients in a given treatment area or unit (e.g., Ambu bag during resuscitation)
- All reusable items, supplies and equipment provided to all patients during inpatient or outpatient admission
- Supplies necessary or integral to provision of a specific service or delivery of services in a specific location
- Cardiac monitors, catheter guidance/guidewires, Foley Stat Lock, Foley/Straight catheters, irrigation supplies, syringes, telemetry battery, wall suction, supplies integral to patient care (e.g., wipes, swabs, bed pans)
Emergency department supplies and services
- All monitoring, equipment, supplies, time, and staff charges
- IV starts, IV administration, IV push, IV flush and assessments, dressing changes, infusion of fluids
Pharmacy services included with facility care
- Administration, documentation, and preparation of drugs in an inpatient setting
- Anesthetic products related to anesthesia maintenance, anesthesia related to surgical procedure and anesthetic reversal agents
- Consultation and advice to medical and nursing staff on drug therapy
- Contrast materials, topical anesthetics, irrigation fluids and materials necessary for preparation and administration of drugs such as small volume diluents (sterile water, normal saline, dextrose, sodium chloride, heparin flushes)

ALL of the following

Violations of this policy may result in increased auditing and monitoring, contractual penalties and/or termination of the contract; disciplinary actions up to termination of employment may apply

ALL of the following

See CMS Provider Reimbursement Manual, RCW 18.79, WAC 246-840, WA DOH Hospital Accounting Manual, and CMS Medicare Benefits/Part B Hospital manuals for related guidance

Not Separately Reimbursable Codes

Not separately reimbursable with noted exceptionCPTCovered

36415

Venipuncture; one allowed per day

Claim Submission and Audit Notes

Documentation Required

Claim submission on UB-04/837I and audit risk

Submit facility claims on the UB-04/CMS-1450 paper claim form or the 837I electronic claim form. The Plan will identify non-reimbursable services through either pre-payment or post-payment hospital claim audit reviews; violations may result in increased auditing, contractual penalties, corrective action, or termination.

Use UB-04/CMS-1450 for paper facility claims or 837I for electronic facility claims.
Be aware that services listed as not reimbursable will be identified in pre- or post-payment hospital claim audits.
Violations can lead to increased monitoring, performance guarantee penalties, corrective action, or contract/ employment termination at the Plan's discretion.

Key Definitions

Charges That Are Not Separately Reimbursable

DefinitionCharges That Are Not Separately Reimbursable: charges that are intrinsically and/or customarily included in room and board or as part of another procedure or service.

ScopeApplies to Premera Blue Cross; Premera Blue Cross Blue Shield of Alaska; LifeWise Health Plan of Washington; LifeWise Assurance Company; and Premera Blue Cross HMO lines of business and products.

Claim FormsFacility claims submitted on UB-04/CMS-1450 or 837I may have these charges identified in pre-payment or post-payment hospital claim audits.

Policy PurposeTo define inpatient and outpatient facility charges considered not separately reimbursable when submitted on UB-04/CMS-1450 or 837I.

Nature of ListProvided examples are not exhaustive; broad categories represent examples of services considered included in the main category based on industry criteria.