Highmark Commercial Medical Policy in West Virginia
Section: Miscellaneous
Number: Z-39
Topic: Provider Overhead Expenses
Effective Date: August 22, 2011
Issued Date: August 22, 2011
Date Last Reviewed:

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.

Additionally, the cost of supplies (e.g., suture removal kits, surgical trays, electrodes) used in providing a covered professional service is included in the allowance for that professional service and should not be billed separately. These supplies include, but are not limited to, those procedure codes listed below.

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

9900099070A4220A4262A4263A4270
A4550A4556A4557A4558A4565A4570
A4580A4590Q4001Q4002Q4003Q4004
Q4005Q4006Q4007Q4008Q4009Q4010
Q4011Q4012Q4013Q4014Q4015Q4016
Q4017Q4018Q4019Q4020Q4021Q4022
Q4023Q4024Q4025Q4026Q4027Q4028
Q4029Q4030Q4031Q4032Q4033Q4034
Q4035Q4036Q4037Q4038Q4039Q4040
Q4041Q4042Q4043Q4044Q4045Q4046
Q4047Q4048Q4049Q4050Q4051S8450
S8451S8452S9109   

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

Provider News

04/2011, Provider overhead expense - additional services listed

References

View Previous Versions

[Version 006 of Z-39]
[Version 005 of Z-39]
[Version 004 of Z-39]
[Version 003 of Z-39]
[Version 002 of Z-39]
[Version 001 of Z-39]

Table Attachment

Text Attachment

Procedure Code Attachments

Diagnosis Codes

ICD-9 Diagnosis Codes

ICD-10 Diagnosis Codes

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 Highmark West Virginia 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.

Highmark West Virginia retains the right to review and update its medical policy guidelines at its sole discretion. These guidelines are the proprietary information of Highmark West Virginia. Any sale, copying or dissemination of the medical policies is prohibited; however, limited copying of medical policies is permitted for individual use.