Mountain State Medical Policy Bulletin
Section: Miscellaneous
Number: Z-39
Topic: Provider Overhead Expenses
Effective Date: July 12, 2006
Issued Date: July 12, 2006
Date Last Reviewed: 07/2006

General Policy Guidelines

Indications and Limitations of Coverage

Expenses such as facility/room fees, heat, light, rent, equipment, and office staff are considered part of a provider's overhead expense and should not be billed separately from his or her professional services.

Separate payment will not be made for any overhead expense. A participating, preferred, or network provider cannot bill the member for these expenses.

NOTE:
Exceptions to coverage for overhead expenses are identified in the individual group's benefits.

Procedure Codes

99000A4220A4262A4263A4270S8450
S8451S8452S8190S9109  

Traditional Guidelines

Refer to General Policy Guidelines

FEP Guidelines

Refer to General Policy Guidelines

PPO Guidelines

Refer to General Policy Guidelines

Managed Care POS Guidelines

Refer to General Policy Guidelines

Publications

PRN References

03/1994, Provider Overhead Expenses, reimbursement for
06/1996, Overhead Expenses, codes and reimbursement for
06/2001, New codes for casting supplies considered overhead expenses
04/2002, Electronic spirometer considered part of overhead expense
10/2004, Highmark considers slings part of overhead expense
02/2006, Supplies and materials considered overhead expenses

References

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Table Attachment

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Glossary




This policy is designed to address medical guidelines that are appropriate for the majority of individuals with a particular disease, illness, or condition. Each person's unique clinical circumstances may warrant individual consideration, based on review of applicable medical records.

Medical policies are designed to supplement the terms of a member's contract. The member's contract defines the benefits available; therefore, medical policies should not be construed as overriding specific contract language. In the event of conflict, the contract shall govern.

Medical policies do not constitute medical advice, nor the practice of medicine. Rather, such policies are intended only to establish general guidelines for coverage and reimbursement under Mountain State Blue Cross Blue Shield plans. Application of a medical policy to determine coverage in an individual instance is not intended and shall not be construed to supercede the professional judgment of a treating provider. In all situations, the treating provider must use his/her professional judgment to provide care he/she believes to be in the best interest of the patient, and the provider and patient remain responsible for all treatment decisions.

Mountain State Blue Cross Blue Shield (MSBCBS) retains the right to review and update its medical policy guidelines at its sole discretion. These guidelines are the proprietary information of MSBCBS. Any sale, copying or dissemination of the medical policies is prohibited; however, limited copying of medical policies is permitted for individual use.