April 15, 2021
The purpose of the Contract Exclusions policy is to define inpatient and outpatient facility charges considered not separately reimbursable but are intrinsically and/or customarily included in room and board or as part of another procedure or service.
The policy is applied to inpatient and outpatient facility claims on a pre- and post-payment review basis.
Although not an all-inclusive list, here are examples of charges that aren’t separately reimbursable:
Nursing services
- Point-of-care testing done at the patient’s bedside
- Blood administration
- Venipuncture
Respiratory services
- Vent management (OR, ICU, CCU, Recovery Room)
- Oxygen
- Respiratory therapy services (OR, ICU, CCU, Recovery Room)
Supplies and/or equipment
- Solutions, fluids, diluent, saline, etc., used to deliver drugs or a flush of IV lines
- Drapes
- Preparation kits
- Ambu bag
- PICC line
These examples are considered charges that are non-reimbursable. When these non-reimbursable charges are identified as billed separately as part of an inpatient or outpatient facility bill audit, they’ll be recovered.
To review these and more examples in the current policy, sign in to our provider website using OneHealthPort.