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Fee Schedule Update

August 30, 2013

Blue Cross and Blue Shield of Texas (BCBSTX) will implement changes in the maximum allowable fee schedule used for BlueChoice®, Blue Advantage HMOSM, HMO Blue® Texas (Independent Provider Network and THE Limited Network only), and ParPlan effective Nov. 1, 2013.

  • The methodology used to develop the maximum allowable fee schedule will continue to be based on 2011 CMS values for those services for which the Blue Cross and Blue Shield of Texas reimbursement is based on CMS values.
  • Reimbursement percentage for the modifier 78 will be revised.
  • A multiple procedure payment reduction will be made on the professional component of certain diagnostic imaging procedures. The reduction applies to professional component only services and the professional component portion of global services for the procedures listed on the website. The highest priced procedure will be reimbursed at 100% of the allowable and each additional procedure, when performed during the same session on the same day, will be reimbursed at 75% of the allowable.
  • Geographic Practice Cost Indices (GPCIs) will not be applied to the relative values so the relative values will not differ by Medicare locality.
  • HMO Blue Texas, BlueChoice, and ParPlan relative values and Blue Advantage HMO weights will consider the site of service where the service is performed (facility or non-facility).
  • The Drug CPT/HCPCS Fee Schedule will be updated on the following dates: 9/1/2013, 12/1/2013, 3/1/2014 and 6/1/2014.
  • Effective December 15, 2013 BCBSTX will begin reimbursing claims submitted with an NDC in accordance with the NDC Fee Schedule posted on the website under "Drugs" at http://www.bcbstx.com/provider/gri/reimbursement_schedules_110112.html. The NDC Fee Schedule will be updated monthly on the first of the month, starting Jan. 1, 2014. Lower cost generic medications may be reimbursed with a larger margin compared to higher cost generic and brand medications. In addition, effective June 1, 2014, BCBSTX will revise the methodology utilized for determining the allowables for CPT and HCPCS codes associated with multiple NDCs. The HCPCS or CPT code allowable generally will be equivalent to the lowest NDC allowable associated with the HCPCS or CPT code.

Blue Cross and Blue Shield of Texas provides general reimbursement information policies, request forms for allowable fees and fee schedule information at bcbstx.com/provider. To view this information, visit the General Reimbursement Information section on this website. If you would like to request a sample of maximum allowable fees or if you have any other questions, please contact your local Provider Relations office.

Reimbursement changes will be posted under "Reimbursement Changes/Updates" in the Professional Reimbursement Schedules section on the BCBSTX Provider website. The changes will not become effective until at least 90 days from the posting date. The specific effective date will be noted for each change that is posted.