November 21, 2019
The Payment Policy Contract Exclusions/Disallowed Charges-Inpatient and Outpatient Facility Services has been expanded to include additional services, both inpatient and outpatient, that will be considered not separately reimbursable when billed on a Facility UB-04 claim form. These services will be identified in either a pre-payment or post-payment hospital claim audit review of hospital charges.
Effective with dates of service March 1, 2020 and after, the following additional services will be considered not separately reimbursable by Premera:
- Blood and Blood Product Administration service: Documentation and preparation of blood products
- Nursing care:
- Expanded to include outpatient services or procedures
- IV Starts, IV Administration, IV Push and assessments, dressing changes, infusion of fluids
- Injections, subcutaneous and intramuscular
- Nasogastric tube insertions
- Point of care/bedside testing (such as blood count, arterial blood gas, clotting time, glucose monitoring etc.), bladder scans
- Dietary services
- Minor medical/surgical supplies
- Medical and psychiatric social services
- Venipuncture performed by a nurse
- Equipment required by a specific level of care room charge: Oxygen per day charges when a patient is confined in a special care unit or part of an outpatient surgical procedure or service
- Operating Room/Surgical Suite:
- Expanded to include outpatient services or procedures
- The use of the operating room, the services of qualified professional and technical personnel, linen packs, basic sterile instrument packs and trays, basic post-op dressing, equipment and routine supplies such as sutures, gloves, dressings, sponges, prep kits, drapes and surgical attire are considered part of standard Operating Room services and not separately reimbursable
- Personal care items used for patient conveniences and items needed as a direct result of a procedure or test considered not separately reimbursable (ex. such as but not limited to deodorant, dry bath, dry shampoo, lotion, mouthwash, powder, soap, telephone calls, television, tissues, toothbrush/toothpaste, bedpans, hot water bottles, icepacks, pillows, sitz baths, urinals, professional manicures, hair styling, etc.)
- Services for facility personnel (reimbursement included in the reimbursement for the procedure or observation charge)
- Central Supply: Supplies provided as part of routine care issued to other departments
- Lab: Transportation fees related to specimen pick ups
- (New section) Emergency Room Supply and Service Charges: All monitoring, equipment, supplies, time, and staff charges
- (New section) Pharmacy Charges furnished to patients:
- Administration, documentation and preparation of drugs in an inpatient setting; allowed when provided in an outpatient infusion center or ER
- Consultation and advice to medical staff and nursing staff on drug therapy
- Cost of materials necessary for the preparation and administration of drugs
- Services rendered by registered pharmacists and other pharmacy personnel (ex: mixing fees, facility staff checking and restocking the pharmacy cart)
Facility providers should review the full payment policy.