For Dates of Service Before January 1, 2019

Reimbursement for Office-Based Services Provided in a Hospital or an Ambulatory Surgery Center

ForwardHealth reduces reimbursement to physicians and other professional service providers for services that are typically provided in an office-based setting when those services are instead provided in a hospital (POS code 21 or 22) or an ASC (POS code 24). The reduced reimbursement is intended to account for the lower overhead costs typically realized by physicians and other professional services providers when services are provided in a hospital or an ASC.

Refer to the table below for the affected codes. The reduced reimbursement for these services when provided in a hospital or an ASC equals 80 percent of maximum allowable fees.

Affected services are reimbursed at the full maximum allowable fee when provided in an allowable POS other than 21, 22, or 24.

For select services (identified on the table by an asterisk), reimbursement reductions apply only for members who are 19 years of age or older on the DOS. For these select services, providers are reimbursed at the full maximum allowable fee when the service is rendered to members who are 18 years of age or younger on the DOS, regardless of POS.

* For these select procedure codes, reimbursement reductions apply only for members who are 19 years of age or older on the DOS.