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Implantable Device Audit Procedure

Provider Administrative Policy

Claims Submission
Policy Date
October 2010
Revised/December 2014
Provider Type(s)
Ambulatory Surgery Centers  


Our provider administrative policies contain information regarding claims submission, reimbursement, and other information in order to achieve an efficient relationship with our providers. These policies are not an authorization or explanation of benefits. Blue Cross of Idaho retains the right to add to, delete from and otherwise modify this policy in accordance with our provider contracts


Implantable Device Audit Procedure

Some services performed in an ambulatory surgery center (ASC) setting may require the use of surgical implants and implantable devices that are not individually priced on the fee schedule. Implants and implantable devices are defined as 1) a biocompatible mechanical device or biomedical material that serves to replace a biological structure, or 2) a device or biomedical material that supports and/or enhances the command and control of a biological process. Furthermore, an implantable device is only one that is intended to remain in the body for a period of 30 or more days. Materials such as, sutures, staples, wire and any other supplies are not separately reimbursable. Implantable drugs or biologicals as defined by CMS, as well as covered contraceptive implants, are reimbursed according to the Fee Schedule.

Reimbursement for implants and implantable devices with an invoice cost of $100 or less are included within the procedural allowance. Reimbursement for implants and implantable devices with an invoice cost greater than $100, are eligible for reimbursement at invoice cost, including shipping and handling, less any associated rebates or discounts received by the ASC. The ASC must submit claims for implants and implantable devices with the appropriate HCPCS code available and at invoice cost. Blue Cross of Idaho may conduct monthly retrospective audits on claims including charges for implants and implantable devices.

We strongly encourage submitting an invoice with claims that include charges for implants and implantable devices, but it is not required. Upon request from Blue Cross of Idaho, the ASC must deliver invoices for implant and implantable devices within 30 days. If the ASC does not provide copies of invoices to Blue Cross of Idaho within the requested period, we will recoup any payments made to the ASC for associated implant reimbursements and take disciplinary actions in accordance with the ASC's contract, up to and including contract termination. We may require prior authorization on some procedures, please refer to PAP241 for prior authorization requirements.

Policy History

Date Action Reason
December 2014 Revised Updated definition of implant. Included shipping and handling in allowance of the implant cost.
July 2012 Revised Updated Language

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