Can we submit UB04 Claim without CPT Codes

Note: Tufts Health Plan has identified that the following Revenue Codes will be accepted when submitted electronically without a corresponding CPT and/or HCPCS procedure code if one cannot be found (however, EDI acceptance does not guarantee payment):

0250 – Pharmacy
0525 – RHC/FQHC visit to facility (not 4)
0251 – Generic
0527 – Visit Nurse to Home HH short area
0252 – Non-Generic
0528 – RHC/FQHC visit to other (not 4, 5)
0258 – IV Solutions
0621 – Incident to Radiology
0259 – Pharmacy — Other
0622 – Incident to other Diagnostics
0270 – M&S Supplies
0656 – Hospice — Inpatient General Care
0271 – Non-sterile Supplies
0659 – Hospice — Other
0272 – Sterile Supplies
0663 – Daily Respite Care
0274 – Prosthetic/ Orthopedic Devices
0681 – Level I Trauma Response
0275 – Pacemaker Supplies
0682 – Level II Trauma Response
0276 – Intraocular Lens
0683 – Level III Trauma Response
0278 – Other Implants
0684 – Level IV Trauma Response
0279 – M&S Supplies – Other
0689 – Other Trauma Response
0370 – Anesthesia
0710 – Recovery Room
0371 – Incident to Radiology
0719 – Recovery Room — Other
0372 – Incident to Other Diagnostic
1000 – General Classification – Behavioral Health
0379 – Anesthesia — Other
1001 – Residential Psychiatric
0392 – Processing and Storage
1002 – Residential Chemical
0524 – RHC/FQHC visit to SNF (Part A)