Maximum Units for Anesthesia
Reimbursement Policy:
Maximum Units for Anesthesia
Effective Date:
December 14, 2020
Purpose:
To provide guidelines for the reimbursement of anesthesia when the maximum allowable units are met. Horizon has established maximum values for anesthesia services, CPT Codes 00100-01999, based on analysis of our claims data, using industry standard methodologies. Excess units of the service will be denied based on our established maximum values.
Scope:
All products are included, except:
- Products where Horizon BCBSNJ is secondary to Medicare (e.g. Medigap).
- COB
- ITS Home In-Network
- FEP
All insured commercial medical plans, Medicare Advantage Plans, and SHBP/SEHBP are included. Other ASO accounts will be included as an opt-in option for additional claims editing on an account-by-account basis.
Policy:
Horizon assigns a maximum number of eligible units for anesthesia codes that may be billed per member, per day. Eligible units are determined based on the number of units billed per procedure code, per member by the vast majority of providers who perform such procedures. Horizon BCBSNJ shall not consider for reimbursement any units above the established maximum number of eligible units.
Procedure:
Horizon BCBSNJ shall deny excess units for anesthesia services when any provider bills a number of units that exceed the established daily assigned allowable unit(s), for that procedure for the same member.
No additional reimbursement shall be made if the provider is capitated or the reimbursement structure for that provider is a global fee.
In instances where the provider is participating, based on member benefits, co-payment, coinsurance, and/or deductible shall apply.
In instances where the provider is not participating, member liability shall be up to the provider’s charge.
Exceptions to the above shall be made on a case-by-case basis or on appeal. Determinations will be made by Horizon BCBSNJ on the need for additional units of service based on the specific circumstances involved in the case, which shall be documented by the provider and submitted with supporting medical records.
Limitations and Exclusions:
While reimbursement is considered, payment determination is subject to, but not limited to:
- Group or Individual benefit
- Provider Participation Agreement
- Routine claim editing logic, including but not limited to incidental or mutually exclusive logic, and medical necessity
- Mandated or legislative required criteria will always supersede.
History:
08/25/2020: Policy approved
Policy136_v1.0_08252020