New payment policy for unbundled services going into effect Jan. 1, 2022
Starting Jan. 1, 2022, we’ll no longer reimburse separately for services that, according to Centers for Medicare & Medicaid Services (CMS) guidelines, are included in the inpatient hospitalization facility charge for the primary service or procedure.
We’re introducing an Unbundling Policy, as part of our existing clinical edits process. Under this new policy, we won’t reimburse separately billed items or services determined to be:
- Included in the customary daily room and board charges
- Included in the facility charge for the primary service or procedure provided
- Excessive or inappropriate
- Personal convenience items
Our clinical edits webpage includes examples of what will no longer be covered. This new policy will apply to all our product lines.
Why are we making this change?
This new policy aligns us with national billing and coding guidelines, as well as CMS reimbursement guidelines – ensuring we reimburse appropriately and help our members receive the right care at the right price.