Facility "Overhead" Reimbursement Policy
While NMHC utilizes Medicare fee schedules and CMS methodology to adjudicating claims, NMHC is not a Medicare entity, and does not recognize or reimburse Facility Overhead Charges.
A Facility Overhead Charge is a clinic charge for any technical component or overhead that is billed by a facility when a professional provider renders covered services to NMHC members in a facility clinic setting.
NMHC defines a facility clinic visit as a preventive, curative, diagnostic, rehabilitative, and/or education service provided to an ambulatory patient in an outpatient setting, whether in a freestanding or attached facility that is either owned, operated, leased, or controlled by the facility.
Some examples of a facility clinic visit include, but are not limited to a member:
- Having blood drawn for lab work at a facility draw station
- Seeing a behavioral health provider on a hospital campus
- Getting an X-ray at a diagnostic center
- Seeing his or her PCP
- Receiving education from a nutritionist
NMHC reimburses professional providers for covered services provided in a facility clinic setting when filed on a CMS-1500 form with place of service codes to include, but not limited to, place of service 11, 20, or 22 (Office, Urgent Care, Outpatient). This reimbursement will always include both the professional services and the associated overhead.
NMHC will not separately reimburse a facility for facility clinic visits and services billed on a UB-04, or any other form, when reported with revenue codes 510-525, 527-529 and any successor codes, including but not limited to the accompanying G Codes.
The technical and overhead component of the facility clinic visit will be included by NMHC in the reimbursement paid to the professional provider for professional services, as reported on the CMS-1500 form, with place of service codes to include, but not limited to, place of service 11, 20, or 22. These services may encompass but are not limited to Evaluation and Management healthcare services provided to NMHC members in a clinic setting.
The facility may not seek reimbursement for any technical or overhead component of the clinic charge from NMHC or from our members. The member is held harmless and may not be balance-billed by the provider for clinic facility charges.
In accordance with the terms of your Agreement with NMHC, we reserve the right to recover overpayments resulting from separately billed clinic/facility fees billed in combination with a professional office/clinic visit claim.