Not separately payable (NSP) procedures

When multiple procedures are billed, no additional payment is made to hospitals for procedures identified as NSP on the Outpatient Fee Schedule. Services identified as NSP are an inherent part of another procedure and therefore are considered packaged services/items for which no separate payment is made. Members may not be balance-billed for any NSP procedure that is not reimbursed by IBC.

Coding discrepancies

Any coding discrepancies should be reported using the NaviNet® web portal. In the Plan Transactions menu, select Claim Inquiry and Maintenance, then Claim INFO Adjustment Submission.

Billing requirements for providers contracted under Ambulatory Payment Classification (APC)   The billing requirements for products reimbursed under APCs are as follows:

  Correlation requirements. The Correlation Edits for Outpatient Claims document will continue to be applied to all claims submitted, including claims submitted for APC reimbursement. Please be sure to use the most recently published correlations edits table.

  Integrated Outpatient Code Editor (IOCE). The IOCE identifies billing errors and indicates what actions to take to rectify a claim, as well as performs the calculations to determine composite rate payments where applicable. All claims submitted will be processed through the IOCE, so any errors will need to be addressed accordingly to ensure that an acceptable claim is received and available for adjudication.

  Modifiers. All modifiers required in accordance with billing guidelines from the CMS will be in effect. In order to receive the correct level of reimbursement, all claims submitted should contain the appropriate modifiers for the services rendered.

Implantable items

The Outpatient Implantable Device Reimbursement List does not apply to APC reimbursement. The reimbursement for implantable items is included in the appropriate surgical procedure and is not paid separately. Please follow CMS billing requirements for modifiers and code combinations for implants.

Billing for physician and advanced practice nurse services 

Physician and advanced practice nurse services may not be billed by a facility using a UB-04 claim form or 837I transaction. These services must be billed by the Physician or advanced practice nurse using his or her NPI on a CMS-1500 claim form or through an 837P transaction. 

Professional office-based services in an outpatient setting 

When a professional Participating Provider performs a service that is considered an office-based service (e.g., office visit, outpatient consultation, professional interpretation and report) in an in a office-based setting (eg, clinic, treatment room) located in a hospital facility, hospital affiliate owned site, etc., the facility is not eligible to receive reimbursement for these services or for any services included in the payment to the professional Participating Provider. However, according to their contract, the facility is eligible to receive reimbursement for any ancillary Covered Services (e.g., laboratory test, radiologic study) related to the office visit or consultation. 

Coordination of Benefits/Other Party Liability 

All claims should clearly indicate if the claim is the result of an accident, such as a motor vehicle accident, or related to employment. Refer to the General Information section of this manual for more details. The claim should be submitted to the appropriate primary insurance carrier and should include all services rendered during the admission or date of service. To ensure that timely filing standards are met, these types of claims should also be submitted to IBC with the appropriate indicator, in the event that the primary insurer denies responsibility for the claim.