Excluded Services
Excluded Services are items and procedures a health plan or government program does not cover and will not pay for, such as cosmetic surgery. Identifying them during eligibility checks protects ambulatory surgery centers from unbillable, non-reimbursable claims.
What are Excluded Services?
Excluded Services are items and procedures that a health plan or government program does not cover and will not pay for. They fall outside the scope of the benefit, regardless of whether the care is medically reasonable for the patient.
Common examples include purely cosmetic procedures and other services a plan explicitly carves out. What counts as excluded depends on the specific plan or program, so the same service may be covered under one policy and excluded under another.
Why do Excluded Services matter in the revenue cycle?
Submitting a claim for an excluded service results in non-payment, leaving the facility with a balance that the payer will not cover. Identifying these services in advance avoids wasted billing effort and unexpected denials.
For ambulatory surgery centers, checking for exclusions during eligibility and benefit verification protects against performing or billing services that cannot be reimbursed. When a service is excluded, the center can address financial responsibility with the patient up front rather than discovering the problem after the fact.
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