PROFESSIONAL PROVIDERS
When a professional provider who performs a service that is considered by the Company to be an office-based service (e.g., office visit, outpatient consultation, professional interpretation and report) in an office-based setting located within a hospital, a hospital facility campus, hospital affiliate, or hospital or hospital affiliate-owned site, division, or other location (e.g., clinic, treatment room), the professional provider must submit a CMS-1500 claim form or the electronic equivalent 837p for the office-based service. In such cases, the office-based service fee is inclusive of the professional provider service performed, as well as the office-based overhead (i.e., practice expense).
FACILITIES
When a professional provider who performs a service that is considered by the Company to be an office-based service (e.g., office visit, outpatient consultation, professional interpretation and report) in an office-based setting located within a hospital, a hospital facility campus, hospital affiliate, or hospital or hospital affiliate-owned site, division, or other location (e.g., clinic, treatment room), the facility is not eligible to receive reimbursement for the professional provider office-based services (i.e., room charge) and any item or service included in the payment to the professional provider. If a UB04 claim form or the electronic equivalent 837i is received from the facility for the office-based services, reimbursement will not be made to the facility.
The facility is eligible to receive reimbursement for any covered ancillary service (e.g., laboratory test, radiologic study) related to the office visit or consultation according to their contract.
BILLING SCENARIO
A professional provider (e.g., physician specialist) completes an initial outpatient evaluation and management (E & M) service in their office or clinic that is located within a facility or on a facility campus.
- Reimbursement to the professional provider for an E & M service includes payment for the E & M services and any costs associated with office-based overhead to the professional provider.
- The facility is not eligible to receive reimbursement for a facility component for the outpatient E & M service performed by the consulting professional provider because payment to the professional provider is inclusive of the office-based overhead (i.e., practice expense).
REQUIRED DOCUMENTATION
The individual's medical record must reflect the medical necessity for the care provided. These medical records may include, but are not limited to: records from the professional provider's office, hospital, nursing home, home health agencies, therapies, and test reports.
The Company may conduct reviews and audits of services to our members, regardless of the participation status of the provider. All documentation is to be available to the Company upon request. Failure to produce the requested information may result in a denial for the service.
