Mountain State Medical Policy Bulletin
Section: Miscellaneous
Number: Z-39
Topic: Provider Overhead Expenses
Effective Date: July 16, 2007
Issued Date: July 16, 2007
Date Last Reviewed: 02/2007

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:
This Medical Policy Bulletin pertains only to professional provider services and related expenses. For information on durable medical equipment (DME), please see Medical Policy Bulletin E-1.
NOTE:
Exceptions to coverage for overhead expenses are identified in the individual group's benefits.

Procedure Codes

99000A4220A4262A4263A4270A4556
A4557A4558S8450S8451S8452S8190
S9109     

Traditional Guidelines

Refer to General Policy Guidelines

FEP Guidelines

This medical policy may not apply to FEP. Medical policy is not an authorization, certification, explanation of benefits, or a contract. Benefits are determined by the Federal Employee Program.

PPO Guidelines

Refer to General Policy Guidelines

Managed Care POS Guidelines

Refer to General Policy Guidelines

Publications

References

View Previous Versions

[Version 001 of Z-39]

Table Attachment

Text Attachment

Procedure Code Attachment


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.