Unbundling Adjustments on Clean Claim Reviews
Customize your policy alerts
Sign up for WellCare Policy CC.PI.10 alerts
Get alerted when Policy CC.PI.10 changes without checking for updates manually.
Monitor payer policy activity
Defines how facility-billed supply and service charges are evaluated for unbundling during clean claim reviews and which items are considered non-separately payable; applies to institutional providers submitting facility claims to the Health Plan.
No material clinical or coverage changes in this revision.
Unbundling Evaluation Criteria
Unbundling evaluation criteria for facility charges
Covered when ALL of the following are met:
ALL of the following
ALL of the following
- Supply/service must be medically necessary and reasonable for diagnosis or treatment or to improve function
Per procedure item 1
- Supply/service must be furnished at the direction of a physician (distinct physician order)
Per procedure item 2
ANY of the following
- Supplies generally available to all patients billed at the same underlying room/board acuity level or ordinarily furnished during a procedure (cost included in underlying room/procedure charge)
Per procedure item 3
- Supplies, items, pharmaceuticals, and services that are necessary or integral to the provision or delivery of a specific underlying service
Per procedure item 4
- Items purchasable over the counter are not separately payable
Per procedure item 5
- Supply fees billed daily or one time that are unidentified and unsupported by medical records or documentation are not reimbursable
Per procedure item 6
- Blood and blood product administration services (including thawing/pooling fees) are not separately reimbursable on inpatient claims
Per procedure item 7
- Pharmacy charges include drug cost and administration/materials; separate pharmacy administration charges are not payable
Per procedure item 8
- Multiple charges for results obtained from the same underlying blood sample analysis are not separately reimbursed; reimbursement is per blood sample analysis performed
Per procedure item 9
- Operating room charge includes use of OR, qualified personnel, linen/basic instrument packs, routine supplies (sutures, gloves, drapes, sponges, prep kits), instrument trays, and robotic technology; these are not separately reimbursable
Per procedure item 10
- Charges for reusable items, supplies and equipment are not separately payable when use does not result in incremental cost
Per procedure item 11
ALL of the following
- All charges are subject to review to confirm the amount billed reasonably and consistently relates to underlying direct and indirect costs
Per payment policy item 12
Company will review facility charges prior to payment as part of clean claim review to identify unbundling and ensure compliance with billing standards; supply/service must be medically necessary and furnished at physician direction.
Non-Separately Reimbursable Items and Coding Notes
| Admission kits | Admission kits |
| Anesthesia supplies, including pharmaceuticals/gases when billed with anesthesia time charges | Anesthesia supplies, including pharmaceuticals/gases when billed with anesthesia time charges |
| Any Linen | Any Linen |
| Bedpans/Urinals | Bedpans/Urinals |
| Beds/Mattresses | Beds/Mattresses |
| Bili light | Bili light |
| Bladder scans | Bladder scans |
| Blood pressure cuffs and monitors | Blood pressure cuffs and monitors |
| Breast milk/storage | Breast milk/storage |
| Capital equipment | Capital equipment |
Actions and Review Process for Providers
Prior review of facility charges for unbundling
Company will review facility charges prior to payment as part of the clean claim review to identify unbundling (routine vs non‑routine supplies) and ensure compliance with billing standards; supplies/services must be medically necessary and furnished at physician direction (distinct physician order).
- The supply or service must be medically necessary and reasonable for diagnosis, treatment, or to improve function (Procedure item 1).
- The supply or service must be furnished at the direction of a physician (distinct physician order) (Procedure item 2).
- Supplies generally available to all patients at the same room/acuity level or ordinarily furnished during a procedure are not separately payable (Procedure item 3).
- Unidentified or undocumented supply fees billed daily or one time are not reimbursable (Procedure item 6).
Definitions
OpenPayer is powered by Trek Health's payer performance platform. Trek continuously ingests, validates, and normalizes Transparency in Coverage data alongside payer policies and other commercial payer data to create a structured payer intelligence foundation. OpenPayer uses this foundation to deliver personalized search results, dynamically generated policy pages, and tailored policy monitoring based on each user's payers, specialties, billing codes, and areas of interest. The same intelligence powers broader payer performance workflows, including reimbursement benchmarking, contract evaluation, payer negotiations, and financial decision-making.