Facility Claims (G0463) Update, Effective Jan. 1, 2026

Jan. 29, 2026

We routinely review our coverage, reimbursement and administrative policies for potential updates. We take into consideration one or more of the following: professional society recommendations, Centers for Medicare & Medicaid Services’ guidance, industry standards and our other existing policies.

As a result of this review, effective Jan. 1, 2026, HealthSpring will:

• No longer deny facility claims billed with Healthcare Common Procedure Coding System code G0463 (hospital outpatient clinic visit for assessment and management of a patient) and revenue code 0510 (hospital-based outpatient clinics) for participating and nonparticipating providers.

• Pay facility claims for both participating and nonparticipating providers when billed with any Current Procedural Terminology (CPT^®) and HCPCS codes and revenue codes 0510-0519 or 0520-0529. A primary care provider or specialist cost share will apply to these claims; the specific amount is based on the member’s benefit plan.

• Continue to pay professional claims billed with 99202-99215 and Place of Service (POS) 19 or 22. No member cost share will be calculated when POS 19 or 22 is present.

If you would like additional information, please contact your Provider Performance Enablement representative.