Non-Reimbursable Services

Policy No: 107
Originally Created: 12/01/2009
Section: Administrative
Last Reviewed: 03/01/2024
Last Revised: 03/01/2024
Approved: 03/14/2024
Effective Date: 04/01/2024

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.

Policy statement

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 (95120-95134).
  • 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 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 (80320-80377, 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 (T1000-T5999).
  • Medicare clinical trial codes (G0293-G0294).
  • Medicare demonstration project codes (G9013-G9140).
  • Medicare status 'B' codes (e.g., 36416, 90885). Note: an exception may be made by the plan for legislative or medical policy reasons (i.e., genetic counseling code 96040).
  • Postsurgical home use of an intermittent PCD (E0676) for the purpose of prevention of venous thrombosis not eligible for reimbursement
  • Quality Measures (e.g., G8635, 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 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 (S0270-S0274).
  • Services which our health plan considers part of another service and therefore not separately reimbursable (e.g., 94760 96904).
  • State Medicaid alcohol and drug abuse treatment services (e.g., H0001-H2037).
  • Surgical techniques requiring use of robotic surgical system (S2900 - list separately in addition to code for primary procedure). Charges for the use of robotic surgical techniques, must be reported and billed as separate line items on the itemized and electronic claims.
  • 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 (e.g., 90660).

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




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