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PAP260

Implantable Device Audit Procedure


Provider Administrative Policy

Section
Claims Submission
Policy Date
October 2010
Status/Date
Revised/July 2011
Provider Type(s)
Ambulatory Surgery Centers  

Disclaimer

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.

Policy

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 medical material(s) inserted into the body, including living, inert, biological material, grafts, plates, screws, or fixation devices, used to correct, protect, or stabilize a deformity where the majority of the product is left under the skin after surgery. 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 allowances. Reimbursement for implants and implantable devices with an invoice cost greater then $100 are eligible for reimbursement at invoice cost less any discounts received by the ASC and charges incurred for shipping, handling, and tax. 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
July 2012 Revised Updated Language

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