Non-Reimbursable Services

Policy No: 107
Originally Created: 12/01/2009
Section: Administrative
Last Reviewed: 03/13/2025
Last Revised: 03/01/2025
Approved: 03/13/2025
Effective Date: 04/01/2025
Policy Applies to: Group and Individual & Medicare Advantage

This policy applies to ASCs, physicians, other qualified health care professionals, laboratories, hospitals, and other facilities.

Definitions

Non-Reimbursable Services
Services that are not eligible for reimbursement.

Policy statement

Providers will not be reimbursed nor allowed to retain reimbursement for services considered to be Non-Reimbursable.

Services defined as Non-Reimbursable Services include, but are not limited to:

  • Allergen provision plus administration combined codes. Services must be broken out and reported using separate codes representing each service (e.g., 95120, 95125, and 95130-95134).
  • Codes identified as not payable to professional providers (e.g., S9083).
  • Codes used in our specific health plan Programs when the provider is not contracted with, or the member not enrolled in that Program (e.g., S0281).
  • Computer assisted musculoskeletal surgical navigational procedures (e.g., 20985, 0054T and 0055T list separately in addition to code for primary procedure).
  • Current Procedural Terminology (CPT®) category II supplemental tracking codes (e.g., 0001F).
  • Drug testing CPT codes (e.g., 80320-80377 and 83992) as our health plan requires the use of the appropriate Healthcare Common Procedure Coding System (HCPCS) G codes.
  • HCPCS National "T" codes established for state Medicaid agencies (e.g., T1000 and T5999).
  • Medicare clinical trial codes (e.g., G0293 and G0294).
  • Medicare demonstration project codes (e.g., G9013-G9140).
  • Medicare status 'B' codes (e.g., 36416 and 90885). Note: an exception may be made by the plan for legislative or medical policy reasons.
  • Postsurgical home use of an intermittent pneumatic compression device (e.g., E0676) for the purpose of prevention of venous thrombosis is not eligible for reimbursement
  • Quality Measures (e.g., G8635 and G9188).
  • Services that are included in a global payment (e.g., per diem or Diagnosis Related Group (DRG) paid in a facility reimbursement and not separately payable to professional, laboratory or ancillary providers (e.g., 99026 and 99190). Facilities that are reimbursed at a global rate are responsible for the entire package of care that the member receives from, or which are ordered by the facility during the stay.
  • Some services that are not direct face-to-face patient care (e.g., 99375).
  • Services for which our health plan does not contract (e.g., S0270-S0274).
  • Services which our health plan considers part of another service and therefore not separately reimbursable (e.g., 94760 and 96904).
  • State Medicaid alcohol and drug abuse treatment services (e.g., H0001 and H2036).
  • Charges for the use of robotic surgical techniques must be reported and billed as separate line items on the itemized and electronic claims (e.g., S2900).
  • Tests, procedures or medical drugs that are considered obsolete in nature (e.g., P2028).
  • Codes for which products are no longer available and/or have no National Drug Code (NDC) assigned.

Please refer to the Coding Toolkit for a comprehensive listing of codes our health plan defines as Non-Reimbursable Services.

References

None

Disclaimer

Your use of this Reimbursement Policy constitutes your agreement to be bound by and comply with the terms and conditions of the Reimbursement Policy Disclaimer.