Non-Reimbursable Services

Policy No: 107
Originally Created: 12/01/2009
Section: Administrative
Last Reviewed: 03/13/2025
Last Revised: 03/01/2025
Approved: 03/13/2025
Effective Date: 04/01/2025
Policy Applies to: Group and Individual & Medicare Advantage

This policy applies to ASCs, physicians, other qualified health care professionals, laboratories, hospitals, and other facilities.

Non-Reimbursable Services
Services that are not eligible for reimbursement.

Providers will not be reimbursed nor allowed to retain reimbursement for services considered to be Non-Reimbursable.

Services defined as Non-Reimbursable Services include, but are not limited to:

• Allergen provision plus administration combined codes. Services must be broken out and reported using separate codes representing each service (e.g., 95120, 95125, and 95130-95134).
• Codes identified as not payable to professional providers (e.g., S9083).
• Codes used in our specific health plan Programs when the provider is not contracted with, or the member not enrolled in that Program (e.g., S0281).
• Computer assisted musculoskeletal surgical navigational procedures (e.g., 20985, 0054T and 0055T list separately in addition to code for primary procedure).
• Current Procedural Terminology (CPT®) category II supplemental tracking codes (e.g., 0001F).
• Drug testing CPT codes (e.g., 80320-80377 and 83992) as our health plan requires the use of the appropriate Healthcare Common Procedure Coding System (HCPCS) G codes.
• HCPCS National "T" codes established for state Medicaid agencies (e.g., T1000 and T5999).
• Medicare clinical trial codes (e.g., G0293 and G0294).
• Medicare demonstration project codes (e.g., G9013-G9140).
• Medicare status 'B' codes (e.g., 36416 and 90885). Note: an exception may be made by the plan for legislative or medical policy reasons.
• Postsurgical home use of an intermittent pneumatic compression device (e.g., E0676) for the purpose of prevention of venous thrombosis is not eligible for reimbursement
• Quality Measures (e.g., G8635 and G9188).
• Services that are included in a global payment (e.g., per diem or Diagnosis Related Group (DRG) paid in a facility reimbursement and not separately payable to professional, laboratory or ancillary providers (e.g., 99026 and 99190). Facilities that are reimbursed at a global rate are responsible for the entire package of care that the member receives from, or which are ordered by the facility during the stay.
• Some services that are not direct face-to-face patient care (e.g., 99375).
• Services for which our health plan does not contract (e.g., S0270-S0274).
• Services which our health plan considers part of another service and therefore not separately reimbursable (e.g., 94760 and 96904).
• State Medicaid alcohol and drug abuse treatment services (e.g., H0001 and H2036).
• Charges for the use of robotic surgical techniques must be reported and billed as separate line items on the itemized and electronic claims (e.g., S2900).
• Tests, procedures or medical drugs that are considered obsolete in nature (e.g., P2028).

• Codes for which products are no longer available and/or have no National Drug Code (NDC) assigned.

Please refer to the Coding Toolkit for a comprehensive listing of codes our health plan defines as Non-Reimbursable Services.

None

Urine Drug Testing

Pneumatic Compression Device