| 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, Physical Therapy Assistants, Occupational Therapy Assistants, Speech Therapy Assistants, and Nurse Midwives will be reimbursed at 85% of the maximum allowable fee as described above based on participating role (primary care or specialist). As it pertains to the aforementioned providers, Drugs, Clinical Lab, Other Lab, Durable Medical Equipment/ Prosthetics and Orthotics will not be subject to the reduction. |
Facility Relative Values
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| 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
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| Durable Medical Equipment/Prosthetics and Orthotics |
Codes not listed may require individual consideration (IC) to determine the BCBSTX compensation allowable amount |
DME Codes can be found under the "Other Codes Schedule" listed below
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| 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.
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.
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| 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, Physical Therapy Assistants, Occupational Therapy Assistants, Speech Therapy Assistants, and Nurse Midwives will be reimbursed at 85% of the maximum allowable fee as described above based on participating role (primary care or specialist). As it pertains to the aforementioned providers, Drugs, Clinical Lab, Other Lab, Durable Medical Equipment/ Prosthetics and Orthotics will not be subject to the reduction. Codes not listed may require individual consideration (IC) to determine the BCBSTX compensation allowable amount. |