CurrentPremera BluecrossPolicy CP.PP.419.v2.6

Contract Exclusions/Disallowed Charges - Inpatient and Outpatient Facility Services

Defines inpatient and outpatient facility charges that the Plan considers not separately reimbursable for Premera Blue Cross and affiliated lines of business; applies to facility claims submitted on UB-04/CMS-1450 or 837I. Affects contracted facilities submitting facility claims.

Policy Summary

PayerPremera Bluecross

PolicyContract Exclusions/Disallowed Charges - Inpatient and Outpatient Facility Services

Policy CodePolicy CP.PP.419.v2.6

Change TypeContent clarifications and example additions

Effective Date

Next Review Date

Key ActionDetermine coverage by verifying member eligibility, benefit limits and applying the Plan's medical policy; final reimbursement is subject to claims adjudication edits and provider scope/fee schedule.

SourceLink

POLICY UPDATE CHANGES

Added additional examples to Contrast section within the Radiology category (Indigo Carmine, Indocyanine green, Isosulfan blue, oral contrast).

Added additional examples of IV fluid materials under the pharmaceutical category (Flex or Viaflex, Piggyback, Plus, QSB, Diluent, base).

Clarified that the policy pertains to facility services billed on a CMS-1450/UB-04 paper claim or 837I electronic claim forms.

Multiple sections (nursing, radiology, pharmacy, equipment, OR suite, medical/surgical supplies, respiratory, lab, ER) have been added/modified over time to expand or clarify non-reimbursable items.

multiple sectionspolicy organizes non-reimbursable items (nursing, equipment, OR, supplies, respiratory, radiology, pharmacy, lab, ER)

one/dayvenipuncture allowance per day (exception to exclusion)

Premera & affiliates

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

The following categories and examples are considered not separately reimbursable by the Plan when submitted on a facility claim (not an exhaustive list):

ALL of the following

Nursing care and treatment
- Admission assessment
- Bedside nursing care carried out by Nurses (RN/LPN) and Certified Nursing Assistants (CNAs)
- Bladder scans
- Dietary and related nursing services
- Hemodynamic monitoring
- Incremental nursing (1:1) and ICU/CCU nursing in scope of normal practice
- IV starts, IV administration, IV push, IV flushes (e.g., Heparin), and related assessments
- Medication administration including vaccines, subcutaneous and intramuscular
- Minor medical/surgical supplies used by nursing
- Monitoring of patients (e.g., oximetry)
- Nasogastric tube insertions
- Nursing/tech time and observation & outpatient services billed on same date as inpatient room and board
- PICC line insertion
- Point-of-care/bedside testing (blood count, ABG, clotting time, glucose monitoring, urine dipsticks, hemoglobin/hematocrit, etc.)
- Syringe pump testing
- Tracheostomy care
- Urinary catheterization
- Personal care items
- One venipuncture (CPT 36415) allowed per day
Equipment considered part of room/level of care
- Arterial and Swan Ganz monitors in ICU/CCU, NICU, Operating Room, Recovery Room
- Cardiac monitors in ICU/CCU, NICU Telemetry/Step Down, Operating Room, Recovery Room
- CO2 End Tidal monitors for ventilated patients and in Operating Room
- Fetal monitors in labor room
- Fluoroscopy/Ultrasound/Vascular access guidance for procedures
- Oximetry monitors
Equipment required for specific service/procedure
- Anesthesia machines
- Robotic surgical systems and computer-aided navigation systems (e.g., DaVinci)
- Scopes (laparoscopes, bronchoscopes, endoscopes, C-Arm/Fluoroscopy)
- Ventilators
- PCA pumps / Pain pumps
- Procedure specific tool kits/instruments, surgical instruments, drills/saws/blades, retractors
Operating Room / Surgical Suite
- Use of the operating room and OR set-up charges
- Linen packs, scopes, sterile instruments, special/custom surgical tools and instrument packs/trays
- Post-op dressings, 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, tubing
- Robotic surgical systems
- Personal care items used for patient convenience (e.g., deodorant, dry bath, lotion, mouthwash, toothbrush/toothpaste, tissues, phone/TV charges, etc.)
Medical / Surgical Supplies
- All items and supplies that may be purchased over the counter (OTC)
- All reusable items, supplies and equipment provided to all patients in a treatment area/unit (e.g., Ambu bag)
- Supplies integral to a specific service or location (provided during inpatient or outpatient admission)
- Cardiac monitors
- Catheter guidance/guidewires
- Foley Stat Lock; Foley/Straight catheters
Respiratory Services
- After hours/call back when facility has 24-hour coverage
- PEEP/CPAP/O2 when patient is on ventilator support
- Pulmonary services such as management of nebulizers/breathing treatments, mechanical chest physiotherapy, swallow testing, IPPB therapy, nebulizer treatments
- Ventilatory support management, maintenance, weaning and extubating
Radiology
- After hours/call back when facility has 24-hour coverage
- Contrast materials (e.g., Gadoteridol, LOCM, Gastrogafen, Gadoterate, Indigo Carmine, Indocyanine green, Iohexol, Isosulfan blue, oral contrast)
- Fluoroscopy/Ultrasound/Vascular access guidance for procedures
- Radiopharmaceuticals (e.g., Technetium Tc-99m)
- Services of qualified facility-employed professional and technical personnel
Pharmacy and Lab
- Administration, documentation, and preparation of drugs in an inpatient setting
- Anesthetic products related to anesthesia maintenance and related agents
- Contrast materials, topical anesthetics, irrigation fluids
- Materials necessary for drug preparation and administration including small volume fluids used as diluent (e.g., Flex or Viaflex, Piggyback, Plus, QSB, Diluent, base, sterile water, Normal Saline, Dextrose, Sodium Chloride, Heparin flushes)
- Radiopharmaceuticals and point-of-care testing; blood draws (venipuncture allowance applies)
Emergency Room Supply and Service Charges
- All monitoring, equipment, supplies, time, and staff charges
- IV starts, IV administration, IV push, IV flush and assessments, dressing changes, infusion of fluids

Policy Identifier & Effective Date Notes

Policy Identifiermixed

CP.PP.419.v2.6

Contract Exclusions/Disallowed Charges - Inpatient and Outpatient Facility Services

Effective date and additions (threshold)

Effective dateEffective with dates of service 03/01/2020 and after

Scope of changeAdditional exclusions applied to multiple categories (blood and blood product administration; expanded nursing care and treatment including select outpatient services; equipment considered required component of room charge; expanded OR/surgical suite to include outpatient services)

Examples added (nursing/outpatient)Injections (SC/IM), nasogastric tube insertions, point-of-care/bedside testing (CBC, ABG, clotting time, glucose monitoring), bladder scans, dietary services, minor medical/surgical supplies, medical and psychiatric social services, venipuncture performed by a nurse

Policy applicationThese additional exclusions apply to facility services submitted on a CMS-1450/UB-04 paper claim or 837I electronic claim with dates of service on/after 03/01/2020

Coverage Determination & Claims Adjudication

Billing Rule

Provider Actions — Coverage Determination & Claims Adjudication

Coverage of any service is determined by a member's eligibility, benefit limits for the service or services rendered and the application of the Plan's Medical Policy. Final payment is subject to the application of claims adjudication edits common to the industry and the Plan's professional or facility services claims coding policies. Reimbursement is restricted to the provider's scope of practice as well as the fee schedule applicable to that provider.

Verify member eligibility and benefits prior to rendering services.
Confirm that services meet the Plan's Medical Policy criteria for coverage.
Anticipate claims adjudication edits and applicable professional or facility coding policies; final reimbursement is subject to these adjudication processes.
Ensure billed services fall within the provider's scope of practice and use the applicable provider-specific fee schedule.
Be aware that the list of non-reimbursable inpatient and outpatient facility charges is illustrative, not exhaustive; services identified as included in room and board or part of another procedure may be denied in pre-payment or post-payment audits.

Charges That Are Not Separately Reimbursable — Definitions

Charges That Are Not Separately Reimbursable — definition

TermCharges That Are Not Separately Reimbursable

DefinitionCharges that are intrinsically and/or customarily included in room and board or as part of another procedure or service

Examples (illustrative, not exhaustive)Blood administration and monitoring; administrative costs for processing/storage of blood; documentation and preparation of blood products; inpatient nursing care and treatment services included in facility charge

Claims handlingThese services are identified as non-reimbursable on facility claims and may be subject to pre-payment or post-payment hospital claim audit review