Independent Lab/Sleep Lab — Blue Advantage HMO Reimbursement Schedules Effective 7/1/14

Reimbursement Changes and Updates 

Reimbursement Changes/Updates 

BCBSTX Relative Values 

Assistant Surgery allowable is 16% of the Surgery rate. Physician Assistants, Advance Nurse Practitioners, Registered Nurse First Assistants, Licensed Surgical Assistants, Clinical Nurse Specialists and Nurse Midwives will be reimbursed 85% of the rates posted on the internet except for Drugs, Clinical Lab, Other Lab, Durable Medical Equipment/Prosthetics and Orthotics. Drugs, Clinical Lab, Other Lab, Durable Medical Equipment/ Prosthetics and Orthotics will be reimbursed at 100% of the rates posted on the internet.

Facility Relative Values 

Non-Facility Relative Values 

Lab 

Professional component for procedures listed on the Lab Schedules will be reimbursed at $5.00 for HMO and $5.50 for PPO.

Codes not listed may require individual consideration (IC) to determine the BCBSTX compensation allowable amount.

Clinical Lab Schedule 

Other Lab Codes Schedule 

Durable Medical Equipment/Prosthetics and Orthotics 

Codes not listed may require individual consideration (IC) to determine the BCBSTX compensation allowable amount.

DME Schedule 

Drugs

The Drug/Injectable Fee Schedule will be updated on March 1, June 1, September 1 and December 1 each year.

Codes not listed may require individual consideration (IC) to determine the BCBSTX compensation allowable amount.

CPT/HCPCS/Drug Schedule 


The NDC Fee Schedule will be updated monthly on the first of the month.

The allowed amount posted for each NDC reflects one unit of measure.  Certain drugs may be administered as partial units (i.e., 0.5 or 0.7), while others may be multiple units (i.e., 2 or 5).  The correct NDC units provided (whether partial, single or multiple) should be used as the multiplier to determine the actual allowed amount.

NDC Drug Schedules
Other Codes 

Procedures not covered in the above reimbursement schedules will be addressed in this section.

Assistant Surgery allowable is 16% of the Surgery rate.

Physician Assistants, Advance Nurse Practitioners, Registered Nurse First Assistants, Licensed Surgical Assistants, Clinical Nurse Specialists and Nurse Midwives will be reimbursed 85% of the rates posted on the internet except for Drugs, Clinical Lab, Other Lab, Durable Medical Equipment/Prosthetics and Orthotics. Drugs, Clinical Lab, Other Lab, Durable Medical Equipment/ Prosthetics and Orthotics will be reimbursed at 100% of the rates posted on the internet.

Codes not listed may require individual consideration (IC) to determine the BCBSTX compensation allowable amount.

Other Codes Schedule 


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