Reimbursement Changes and Updates
Prior to January 9, 2023: Reimbursement Changes/Updates
As of January 15, 2023: 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 website 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 website.
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.
Drugs
The Drug/ BCBSTX vaccine pricing methodology is based on the CDC Centers for Disease Control (CDC) Private Sector Cost when available. BCBSTX monitors the CDC Private Sector Cost webpage for monthly changes in vaccines in an effort to adjust its reimbursement with the changes that may occur with the CDC Private Sector rate changes. When new vaccine codes are released or increases are issued, we will price them based on the percentage of the CDC Private Sector Cost disclosed in the provider participation letter. In the event there is not a CDC Private Sector rate, BCBSTX will utilize other sources, including but not limited to public sector Average Wholesale Price, Maximum Allowable cost, and Wholesale Acquisition cost.
*Disclaimer: In the event the CDC Private Sector rates change, BCBSTX attempts to update their reimbursement schedules within thirty (30) days for vaccine pricing increases and no later than ninety (90) days.
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.
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.
The NDC Fee Schedule will be updated monthly on the first of the month.
Other Codes
*Due to COVID-19 procedure codes listed below are appropriate for Independent Lab providers, procedure codes/allowable not applicable to Sleep Labs.
G2023-$23.46 Effective 3/1/2020 - 05/11/2023
G2023/26-$14.08 Effective 12/15/2020 - 05/11/2023
G2023/TC-$9.38 Effective 12/15/2020 - 05/11/2023
G2024-$25.46 Effective 3/1/2020 - 05/11/2023
G2024/26-$15.28 Effective 12/15/2020 - 05/11/2023
G2024/TC-$10.18 Effective 12/15/2020 - 05/11/2023
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 website 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 website.
Codes not listed may require individual consideration (IC) to determine the BCBSTX compensation allowable amount.