Assignment of Benefits

As referenced in both the Enrollee’s Evidence of Coverage and QualChoice Provider Agreements, an Enrollee’s (Member’s) rights and benefits under the Health Plan shall not be assignable or transferable, either before or after services and supplies are provided and/or claims are submitted to QualChoice. Under no circumstances will any provider, whether In-Network or Out-of-Network, assert any claim on the basis that provider is a “participant” or “beneficiary” of the Enrollee’s Health Plan.

With respect to Out-of-Network Providers, QualChoice hereby reserves the right to direct payment directly to the Enrollee. The payment the Enrollee receives from QualChoice will represent the benefit amount payable by QualChoice for the service and will be attached to an EOB. The Enrollee will be responsible for making payment to the non-participating provider for the full amount of the check mailed to the Enrollee, in addition to any applicable co-payment, deductible, coinsurance or other cost share allowances, according to his or her benefit plan.

NOTE: Directing payment to the Enrollee rather than the non-participating provider does not change the determination of coverage, benefit level, or pricing for a non-participating provider claim - only the recipient of the payment.

Billing Practices

Network providers are prohibited by contract from billing the member above and beyond their normal co-payment, coinsurance and deductible. Arkansas state law also prohibits providers who are contracted with a health maintenance organization from billing the member of the health maintenance organization above and beyond their normal co-payment, coinsurance and deductible. Network providers are also prohibited from billing the member for services that require pre-authorization, but for which pre-authorization was not obtained. This applies equally to the network provider who has primary responsibility for obtaining pre-authorization and to other network providers supplying related services that have a responsibility for verifying that pre-authorization was obtained.

Network providers are prohibited by contract from billing the member for services that are denied as not medically necessary unless the network provider has notified the member that the service is not medically necessary prior to the rendering of the service, and the member has agreed in writing that the specific service will not be covered and accepts responsibility for payment for that service. A copy of this agreement must be kept in the provider’s office and made available to QualChoice upon request.

Network providers are prohibited from balance billing a member for amounts in excess of the member’s co-payment, coinsurance and deductible.

If a provider, billing service, or collection agency improperly bills or collects money from a member in violation of the Provider Agreement or this Provider Manual, provider may also be excluded from the QualChoice network for failure to adhere to the "hold harmless" agreement.

DME, Labs, and Cardiac Monitoring - Special Requirements

The following requirements apply to all QualChoice participating providers and health care professionals, and to all laboratory services, clinical and anatomic, ordered by physicians and health care professionals.

Durable Medical Equipment (DME)

QualChoice requires pre-authorization for some DME. Please review our pre-authorization list and medical policies for more information. Durable medical suppliers are listed in the Ancillary section of our Provider Directory.

Subject to the exceptions noted below, all DME, orthotics, prosthetics and supply items must be obtained from a participating provider.

If an item is not available from a participating provider, whether or not pre-authorization is required, the ordering physician must submit an Out-of-Network Authorization Request Form or a letter of medical necessity. Unless the member has an out-of-network benefit for DME, payment will be denied if this information is not submitted.

For further information, see Out-of-Network Referrals.

NOTE: Even when medically necessary certain items (for example, some orthotic devices), may not be covered under a member’s benefit plan. Other items (for example, prosthetic devices) may be subject to benefits limits. Please contact a Customer Service representative for specific information about a member’s benefit plan and any additional pre-authorization requirements.

Laboratory Services

QualChoice maintains a robust network of more than 25 national, regional and local providers of laboratory services. These participating laboratories provide a comprehensive range of laboratory services on a timely basis to meet the needs of our participating physicians. These participating laboratories also provide clinical data and related information to support HEDIS reporting, care management, and other clinical quality improvement activities. It is important to note that in many benefit plans, members receiving services in out-of-network laboratories may incur increased financial liability and therefore higher out-of-pocket expenses.

Participating providers are contractually required to refer laboratory services to a participating laboratory provider, except as otherwise pre-authorized by QualChoice or a payer. Participating laboratory providers are listed in the Ancillary section of our Provider Directory. If you need assistance in locating or using a participating laboratory provider, please contact your Provider Relations Representative.

IMPORTANT NOTE: In the unusual circumstance that you require a specific laboratory test for which you believe no participating laboratory is available, please contact QualChoice in advance to confirm that the specific laboratory test is covered. We will work with you to assure that those covered tests are performed, even if that means the use of a non-participating laboratory. In this event, QualChoice may require use of a particular non-participating laboratory, and will not cover charges for the test if not done at the required laboratory.

For further information, see Out-of-Network Referrals.

Cardiac Monitoring Services

Participating providers are required to refer cardiac monitoring services to a participating provider in the QualChoice network, unless otherwise pre-authorized by us or a payer. QualChoice maintains a network of more than 7 national, regional and local providers of cardiac event monitoring services (for example, CardioNet, Inc., Telerhythmics, Inc., Heart Care Corp of America, Philips Remote Cardiac Services, etc.) who provide a comprehensive range of services on a timely basis to meet the needs of our participating providers.

Participating cardiac monitoring services are listed in the Ancillary section of our Provider Directory. For assistance in locating or using a participating cardiac monitoring provider, please contact your Provider Relations Representative.

In the unusual circumstance that you require a specific cardiac monitoring test for which you believe no participating provider is available, please contact QualChoice in advance to confirm that the specific test is covered. We will work with you to assure that those covered tests are performed, even if that means the use of a non-participating provider.

Administrative actions for use Out-of-Network DME, Lab, or Cardiac Monitoring Services

We anticipate that virtually all participating physicians will be able to easily find a participating DME, lab, or cardiac monitoring supplier that will meet their needs. If we identify an ongoing and material practice of referrals to out-of-network providers, we will inform the responsible participating provider of the issue and remind them that physicians in the QualChoice network are required by contract to refer their patients to in-network providers. While it is our expectation that this will rarely be necessary, please note that continued referrals to out-of-network DME, lab, or cardiac monitoring suppliers may, after appropriate notice, be subject to administrative action.

Modifiers 25, 50, 57, 59, 91

Modifier 25

Modifier 25 is used when, on the day a procedure or service was performed, the patient’s condition required a significant, separately identifiable E/M service above and beyond the other service provided or beyond the usual preoperative and postoperative care associated with the procedure that was performed.

All surgical procedures and some procedural services include a certain degree of physician involvement or supervision which is integral to that service. For those procedures and services a separate E/M service is not normally reimbursed. However, a separate E/M service may be considered for reimbursement if the patient’s condition required services above and beyond the usual care associated with the procedure or service provided. To identify these circumstances, modifier 25 is attached to the E/M code.

The submission of modifier 25 appended to an E/M code indicates that documentation is available in the patient’s records for review upon request that will support the significant and separately identifiable nature of the E/M service.

For additional details, reference BI094 in medical policies.

Modifier 50

This modifier is used to report bilateral procedures that are performed during the same session.

  • Charges must be submitted on two lines.
  • The first line should include a descriptive modifier, i.e., LT (left side) or RT (right side)
  • Modifier 50 should be in the first modifier position on the second line. The descriptive modifier is in the second position.
  • If a provider bills a bilateral surgery on one line with Modifier 50, the payment will reflect one-half of one side. A corrected claim must be submitted to obtain correct payment. 

Modifier 57

Modifier 57 is used when the initial decision to perform a major surgical procedure is made during an E/M service provided the day before or the day of a major surgery. Major surgery is defined as any code having a 90 day global period.

The submission of modifier 57 appended to an E/M procedure code indicates that documentation is available in the patient’s records confirming that the E/M service resulted in the initial decision to perform the surgery.

An E/M service provided the day before or the day of a major surgery that resulted in the initial decision to perform surgery may be eligible for reimbursement if modifier 57 is appended to the E/M code. Modifier 57 should not be used when the E/M service is associated with a minor surgical procedure (defined as having a 0 or 10 day global period). Modifier 57 should not be used when the E/M service was for preoperative evaluation.

Modifier 59

Modifier 59 is used to identify procedures/services that are commonly bundled together but are appropriate to report separately under some circumstances. A provider may need to use modifier 59 to indicate that a procedure or service was distinct or independent from other services performed on the same day. This commonly means a different location, different anatomical site, and/or a different session.

Providers must maintain adequate documentation in the medical record to support the use of modifier 59 for distinct services. Addenda or amendments to the documentation will not be accepted after a claim has been denied. If a claim line is denied due to a clinical edit and you submit a corrected claim using modifier 59 for that claim line, we will require medical records in order to process the corrected claim. Different diagnoses are not adequate criteria for use of modifier 59.

Using modifier 59 with physical therapy codes:

When appending modifier 59 to physical therapy codes; the documentation must support that distinct services (different session/patient encounter or different procedure/service) were rendered. Appending this modifier should be the exception, not the rule. Overusing this modifier may trigger a review of medical records or an audit of your claims.

Inappropriate use of modifier 59

In many cases, there is a more suitable modifier that may expedite claims processing. Modifier 59 should only be used if no other modifier more appropriately describes the relationship(s) of the two or more procedure codes. For example, when commonly bundled procedures are performed on different fingers or toes, the use of finger (F1, F2, F3, etc.) or toe (T1, T2, T3, etc.) modifiers would be more appropriate than the 59 modifier to show that these are distinct services and create a clearer picture for the claim examiner as to why the services were unbundled. This may reduce the need for operative notes or medical office notes.

Other examples when modifier 59 is not appropriate include unlisted codes or with some HCPSC or CPT codes, such as J codes or L codes.

Modifier 91

Modifier 91 is used to report repeat laboratory tests or studies performed on the same day on the same patient. This modifier is added only when additional test results are to be obtained subsequent to the initial administration or performance of the test(s) on the same day, or when two different tests done on the same day are described by the same code. It is not used when laboratory tests or studies are simply rerun because of specimen or equipment error or malfunction. Nor is it to be used when a test is repeated to confirm initial test results. Further, based on the definition of modifier 91, it should not be reported when the basic procedure code(s) indicate that a series of tests are to be obtained. CPT codes for use with modifier 91 are in the laboratory code range 80047-89398.

Definition - Modifier 91

Repeat clinical diagnostic laboratory test. In the course of treatment of the patient, it may be necessary to repeat the same laboratory test on the same day to obtain subsequent (multiple) test results.

Appropriate Usage - Modifier 91

  • To identify a subsequent medically necessary laboratory test on the same day of the same previous laboratory test.

Inappropriate Usage - Modifier 91

  • Used for a rerun of a laboratory test to confirm results
  • Due to testing problems for the specimen
  • Due to testing problems of the equipment
  • When another procedure code describes a series test
  • When the procedure code describes a series of test
  • For any reason when a normal one time result is required

Anesthesia Services Reporting Requirements

Anesthesia services are paid based on Anesthesia Relative Value Units. The customary values for reimbursement of anesthesia services are based on the sum of the components listed below. 

  • Base units for the primary procedure
  • Total time
  • Physical status

Subrogation

To the extent permitted under applicable state and federal law and the applicable benefit plan, QualChoice reserves the right to recover benefits paid for a member’s health care services when a third party causes the member’s injury or illness. If a QualChoice member who has been involved in a motor vehicle accident or workers’ compensation injury visits your office, you should:

  1. Record the name of the member's automobile insurance company and/or their workers' compensation carrier
  2. Verify the member's eligibility through QualChoice
  3. Submit any claims to QualChoice

Following these steps will expedite processing and help ensure that the claim is paid accurately. Once the claims are submitted, QualChoice works with a third-party subrogation vendor to determine if the member’s automobile insurer or the workers’ compensation carrier is responsible for paying the claims (this process varies depending on the Provider’s Agreement or the member’s benefit plan).

Workers' Compensation

If the claims are determined to be work-related they will be denied.  The provider will be notified to file a claim through the applicable workers' compensation carrier or the member's employer group. If QualChoice inadvertently or mistakenly pays a claim on a work-related injury or illness and later discovers that the injury or illness was work-related, we will take steps to obtain appropriate recoveries from all parties who have been issued benefits for the claim. QualChoice may in its sole discretion process, adjudicate and pay the claim on behalf of the employer group, but will notify the facility and all involved parties of the pending workers' compensation claim and of our intention to seek recovery of benefits paid for such claim.

Our EOC, COC and Summary Plan Descriptions exclude all expenses incurred by a member as a result of injury or illness that occurs on the job.

QualChoice will reimburse the network provider according to the terms of their Provider Agreement for any Covered Services that are billed. Please note that members injured in these situations should not have to pay for medical services at the time of the visit, other than the applicable co-payment, coinsurance or deductible amount.

Coordination of Benefits (COB)

COB is administered according to the member’s benefit plan and in accordance with applicable law. QualChoice coordinates benefits when members are covered by more than one plan. When the QualChoice plan is considered primary coverage, we will reimburse the full extent of Covered Services at the plan agreed reimbursement rate, less any applicable co-payment, coinsurance or deductible. When QualChoice is secondary, we may reduce the benefits we pay so that payments from all health policies do not exceed 100% of the COB Allowable Expense.

Allowable Expense is a healthcare expense (including deductible, coinsurance or co-payments) covered in full or in part by any healthcare plan or policy covering the Enrollee. This means an expense or service not covered by any plan or policy covering the Enrollee is not an Allowable Expense. Also, any expense that a provider by law or in accordance with a contractual agreement is prohibited from charging an Enrollee is not an Allowable Expense.

If two (2) or more plans or policies cover an Enrollee and compute their benefit payments based on that plan’s maximum allowable charge, then any amount in excess of the highest reimbursement amount for a specified benefit is not an Allowable Expense.

If two (2) or more plans or policies cover an Enrollee and provide benefits or services based on negotiated fees, then any amount in excess of the highest of the negotiated fees is not an Allowable Expense.

If you are covered under multiple plans or policies and the Allowable Expense is determined by more than one method, then the primary policy’s payment arrangement shall be the Allowable Expense for all plans or policies.

The QualChoice plan will never pay more than it would have as the primary plan. When the QualChoice plan is primary and there is a balance after the QualChoice plan has paid for Covered Services according to the agreed upon rate, the provider may balance bill the secondary carrier. If the QualChoice plan is secondary, and there is a balance after the primary plan has made payment, and QualChoice has reimbursed the appropriate amount for Covered Services, the provider may not balance bill the member.

Whether QualChoice is the primary or secondary carrier, claims must be submitted within the timely filing time frame specified in the Provider's Agreement. QualChoice is under no obligation to pay claims received past this specified time frame and the member cannot be balance billed for claims denied due to late submission.

Payments and Offsets

Timing of Payments

QualChoice shall pay or provide network provider written notice of payment status for services provided to members in accordance with their Provider Agreement and no later than 45 days immediately subsequent to receipt of a complete and accurate claim which requires no additional information or investigation for payment determination.

Recovery of Payments

For overpayments made due to an error on the part of QualChoice, a payer, plan administrator or one of its representatives:

QualChoice may deduct from payments the amount of any previous payments received for services subsequently determined by the applicable payer or plan administrator to be overpayments. The request for recovery of payments must be sought within 180 days of the date of the payer’s remittance advice which contains the payment(s) to be recovered. If such erroneous payments are not completely recoverable from future claims payments within a reasonable period of time, the network provider agrees to repay such un-recovered overpayments to payer or health plan within 30 days of written request.

Erroneous overpayments include, but are not limited to:

  • payment for services that are not Covered Services; or,
  • duplicate payment; or,
  • any overpayment improperly or mistakenly paid due to an error on the part of the payer or plan administrator.

For overpayments made due to an error on the part of network provider or one of its representatives:

Network provider agrees to accept as deductions from payments the amount of any previous payments received for services subsequently determined by the applicable payer or plan administrator to be overpayments. The request for such recovery of payments must be made within 12 months of the date of the payer’s remittance advice which contains the payment(s) to be recovered. Should the erroneous payment not be completely recoverable from future claims payments within a reasonable period of time, the network provider shall repay un-recovered overpayments to QualChoice within 30 days of written request.

Erroneous overpayments include, but are not limited to;

  • payments made for services that, based on the information presented to payer or plan administrator, were considered Covered Services at the time payment was made, but which were subsequently determined not to be Covered Services, based on an audit of medical records; or,
  • payments made based on coding not substantiated in the medical records; or,
  • any overpayment, improperly or mistakenly paid due to any other error on the part of the network provider.

The above limitations do not apply to overpayments made through fraud or misrepresentation by the provider. Recovery of such overpayments is only restricted by applicable law.

Payment Reconsideration and Appeals

All participating providers have a right to request reconsideration of any payment determination made by QualChoice.

A Request for Reconsideration form must be submitted within 180 days of the date of the original RA unless state or federal law or the Provider’s Agreement reference another time period. The request should include any medical records relevant to the dispute. Failure to include required information will result in the request being rejected.

For greater efficiency, providers are encouraged to pursue resolution with a Customer Service representative prior to filing a reconsideration request.

Note: The above provisions of this section are to be considered as separate and distinct from the arbitration provisions set forth in the Provider’s Agreement.

Member Obligations

Member Cooperation Affects Reimbursement

All member health plans and contracts define areas in which the member's cooperation is needed to adequately process claims or provide good customer service. If the member fails to provide that cooperation, QualChoice may not be able to determine benefits, or may decide to deny benefits for lack of cooperation. The charges for services would then become the member's responsibility.

Because provider reimbursement is subject to the terms of the member's health plan or contract, providers should be aware of the terms of the health plan or contract, including those terms that require member cooperation. Providers should encourage our members who are patients to fully cooperate in providing all information needed to properly evaluate and effectively process their claims.

If the member fails to cooperate and claims are denied on that basis, providers will not be entitled to any reimbursement from QualChoice for the services in question.

Areas in which we need and request member cooperation include but are not limited to:

  1. Obtaining medical records or other claims-related information;
  2. Obtaining information regarding other coverage the member may have (coordination of benefits);
  3. Obtaining information regarding the status of a dependent, such as a disabled child or a college student; and,
  4. Obtaining information regarding third party liability (e.g., auto accident), subrogation or work-related injuries.

Member Financial Obligations

In most situations, members are responsible for part of a network provider's bill for services (i.e., the member’s co-payment, coinsurance and deductible) as specified in the member's health plan or the Provider’s Agreement.

Member Responsibility for Non-Covered Services

Network provider may charge a member for services determined by QualChoice or the applicable payer to be excluded from the member’s health plan or services which would otherwise be Covered Services, but which have been determined to be not medically necessary under the following conditions:

  • the network provider has confirmation from QualChoice or the plan administrator before the service is provided that the service is not a Covered Service or is not medically necessary;
  • the member requests and agrees in writing before the services are provided to pay for such services after having been fully informed by the network provider that such services are not covered under their health plan;
  • the written agreement must be specific to the service being provided; (a blanket agreement to be responsible for any services deemed not medically necessary is not acceptable), and;
  • a copy of the written agreement is kept un the member’s medical records in the network provider’s office and provided to QualChoice upon request.

Member Fraud or Misrepresentation

If a member has obtained coverage by means of an application that misrepresented the member's past medical history or other relevant background, or if a member has filed fraudulent insurance claims, we may elect at our discretion to terminate the member's health plan coverage or insurance contract, or to rescind the coverage.

If coverage is rescinded, that action is retroactive to the first date that the member's coverage became effective, even if that date was months or even years before the fraud or misrepresentation was made known. This means that the member, in effect, never had any coverage because the coverage was obtained through fraud or material misrepresentation.

Accordingly, providers may be asked to refund prior claims payments made with respect to such a member, and any pending claims with respect to such a member will be denied on grounds that no coverage existed on the date of service.

It is in a provider's best interest to identify any member fraud or misrepresentation as early as possible, not only to protect all members and the public at large from the costs of such improper activity, but also to protect providers.

Note: In order to avoid potential problems with identity theft or fraud, ask the member for a separate form of identification, preferably photographic, along with the member’s QualChoice ID card.

Please report fraud, waste or abuse through any of the following means:

  • Fraud & Abuse Telephone Hotline: 501.228.7111 or 800.235.7111, ext. 6740, or 501.707.6740
  • Fax: Attention Fraud & Abuse Dept: 501.228.0135
  • E-mail: Fraud@qualchoice.com
  • Mail: QualChoice | Attn: Fraud, Waste and Abuse Department | P. O. Box 25610 | Little Rock, AR 72221

All reports are treated as confidential and will be investigated as appropriate, including applicable referral to law enforcement and regulatory bodies. Please include as much detail as possible to ensure our ability to investigate each issue. Reports may be made anonymously.

QualChoice Claim and Payment Integrity Audits

QualChoice utilizes external audit firms such as CERiS and Equian to perform various claim and payment integrity audits.  These audits will cover areas such as Subrogation, Coordination of Benefits, DRG Validation, and Hospital Bill Audits. 

Subrogation

Coordination of Benefits

DRG Validation

QualChoice, through it’s delegated audit vendors, will review medical records to validate proper code billing and DRG assignment. Medical records are reviewed to validate and confirm the clinical significance and accuracy of each recorded diagnosis. Specialized DRG coding software ensures the accuracy of the principal diagnosis and that inpatient claims are paid at the appropriate rates.  

Hospital Bill Audits

Consistent with guidelines set forth by the Centers for Medicare and Medicaid Services (CMS), QualChoice will not reimburse for covered medical and surgical services and supplies that should be included in the general cost of the room where services are being rendered or the reimbursement for the associated surgery or primary procedure.  Surgical and medical supplies are used in the course of services performed/care provided in the inpatient hospital, outpatient hospital, ambulatory surgery center (ASC), and other institutional health care settings. These are not medical necessity denials.  Instead, payment for the comprehensive procedure includes any separately identified component parts of the procedure.   

Many supply items have HCPCS codes. Some HCPCS for supply items may even have RVU values on the CMS Physician Fee Schedule. Despite this, supplies used in conjunction with care provided in inpatient or outpatient institutional settings generally may not be separately reported and are not eligible for separate reimbursement based on industry standard guidelines. 

Billing of both services provided and the associated supplies used must follow correct coding and billing guidelines. Providers should ensure that all non-routine, billable supplies are classified under the appropriate revenue code. 

This policy is intended to be consistent with the guidelines set forth by CMS.  However, this does not mean, nor does it imply, that any items or services are separately billable to QualChoice merely because CMS has not denied separate reimbursement for those items or services.

Reimbursement Guidelines

Outlier Calculation:

Routine services and supplies are not separately billable and are items that are included in the general cost of the room where services are being rendered or the reimbursement for the associated surgery or primary procedure. These items, if identified on an Outlier claim or itemized bill, are not eligible for separate reimbursement, and are not eligible to be included in outlier calculations for additional reimbursement.

General types of routine services and supplies that are not separately billable include:

  1. Any supplies, items, and services that are necessary or otherwise integral to the provision of a specific service and/or to the delivery of services in a specific location are considered routine services and not separately billable in the inpatient and outpatient environments
  2. All items and supplies that may be purchased over-the-counter are not separately billable
  3. All reusable items, supplies and equipment that are provided to all patients during an in or outpatient admission are not separately billable.
  4. All reusable items, supplies, and equipment that are provided to all patients admitted to a given treatment area or unit (i.e. NICU, Burn Unit, PACU, Medical/Surgical) are not separately billable.
  5. All reusable items, supplies and equipment that are provided to all patients receiving the same service (i.e., an Ambu bag during resuscitation) are not separately billable.

Routine Supplies:

Routine supplies should not be billed in the non-covered charge column on the UB-04. The costs for the routine supplies are covered, because they are factored into the setting or procedure charge. Although they are covered, they are not billed separately.  Examples of routine supply items not separately billable are as follows (list is not all inclusive):

  • Personal convenience supply items
  • Gowns used by staff
  • Gloves used by staff
  • Masks used by staff
  • Oxygen when not specifically used by the patient
  • Items ordinarily used for or on most patients in that area or department
  • Thermometers
  • Patient gowns
  • Items commonly available to patients in a particular setting (e.g. stock or bulk supply)
  • Equipment commonly available to patients in a particular setting or ordinarily furnished to patients during the course of a procedure, whether hospital-owned or rented, and supplies used in conjunction with this equipment
  • Oxygen masks and oxygen supplies
  • Drapes
  • Preparation kits
  • Any linen
  • Syringes
  • Saline solutions
  • Irrigation solutions
  • Reusable items
  • Cardiac monitors
  • Oximeters
  • IV pumps
  • IV tubing
  • Blood pressure monitors and/or cuffs
  • Thermometers
  • Ice bags or packs
  • Heat light or heating pad
  • Wall suction
  • Admission, hygiene, and/or comfort kits or items (Administar16, BCKS19)
  • Restraints (Administar16)
  • Reusable equipment and items (Administar16, BCKS19, Administar20)
  • Items used to obtain a specimen or complete a diagnostic or therapeutic procedure (DeWald17)
  • Telemetry batteries, leads
  • Batteries for any equipment used during any procedures

Flushes, Diluents, Saline, Sterile Water, etc:

Heparin flushes, saline flushes, IV flushes of any type, and solutions used to dilute or administer substances, drugs, or medications are included in the administration service. These items are considered routine supplies and are not eligible for separate reimbursement.  Despite the fact that J1642 (Injection, heparin sodium, (heparin lock flush), per 10 units) describes heparin flushes, heparin flushes are not considered a “drug” but rather a supply and heparin flushes are not eligible for separate reimbursement under the fee schedule or provider contract provisions for drugs.

Components of Room and Board:

Items and services that are considered components of room and board charges as not separately reimbursable. Facilities will not be reimbursed nor allowed to retain reimbursement for services considered to be non-reimbursable.

Pharmacy and Lab Services:

Over-the-counter (OTC) drugs are considered part of the room and board and will not be reimbursed separately.  Blood draws from capillary, arterial or vascular access devices regardless of practitioner performing the draw and regardless of whether arterial, venous or capillary blood is drawn. Each blood draw or collection is part of the lab test and is not separately reimbursable.

Equipment:

Equipment that is a required component of a specific level of care and is used in the provision of services to multiple patients and has an extended life, is not separately billable. This equipment is considered a fixed asset of the facility. Calibration of instrumentation is not separately billable as well. 

Where specific procedure codes exist, the services provided with that equipment may be billed as appropriate (e.g. x-rays, dialysis) and in accordance with correct coding and billing guidelines (e.g. no unbundling of oximetry checks, or fluoroscopy in the OR). If specific procedure codes do not exist, in most cases the services provided by that equipment are included in a larger, related service, and are not eligible for separate reimbursement (e.g. thermometer).  Furthermore, equipment used multiple times for multiple patients (should be part of facility charge) and is not separately billable or reimbursable. 

Respiratory Therapy Services and Supplier:

Respiratory care (respiratory therapy) is defined as those services prescribed by a physician or a non-physician practitioner for the assessment and diagnostic evaluation, treatment, management, and monitoring of patients with deficiencies and abnormalities of cardiopulmonary function. Respiratory services may be performed by respiratory therapists, physical therapists, nurses, and other qualified personnel. Documentation in the medical record must clearly support the need for respiratory therapy services to be separately reimbursed.