Reimbursements

Category:

Reductions for Qualified Healthcare Provider’s (QHP) Allowed Amount

Reimbursement Policy NDRP-MISC 003
Topic Reimbursement
Effective Date: July 1, 2019
Last Reviewed:
August 28, 2019

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BCBSND allowed amount reductions may occur for a variety of reasons. Below are various conditions that may reduce allowed amounts from the BCBSND Fee Schedule. QHPs with a specific contracted fee schedule must refer to the contracted fee schedule for reduction details.

Reduction Reason Description
 Certified Diabetic Educator

 Licensed Registered Dietician

Allowed at 85% of PPS

Exceptions are 100% of PPS for:

  • 98960 – 98962, G0108, G0109, and S9145
 Chiropractor Allowed at 85% of PPS

Exceptions are 100% of PPS for:

  • Laboratory/Pathology services, DME and Prosthetics, Physical and Occupational Therapies/Modalities, Radiology services, and Diagnostic tests
 Certified Registered Nurse Anesthetist Allowed at 85% of PPS for non-anesthesia services
 Clinical Nurse Specialist

 Nurse Midwife

 Nurse Practitioner

 Physician Assistant

Allowed at 85% of PPS

Exceptions are 100% for PPS for:

  • Laboratory/Pathology services, Injectables or infused drugs including administration, DME and Prosthetics, Radiology services, and Diagnostic tests
 Licensed Addition Counselor Allowed at 75% of PPS

Exceptions are 100% of PPS for:

  • Laboratory/Pathology services
  • H0004, H0005, and H2035

Exceptions are 50% of PPS for:

  • 90791, 90832, 90834, 90837, 90839, and 90840
 Licensed Clinical Social Worker

 Licensed Marriage Family Therapist

 Licensed Professional Clinical Counselor

Allowed at 75% of PPS
 Licensed Master Social Worker

 Licensed Professional Counselor

 Naturopath

Allowed at 50% of PPS
 Local Public Health Unit Allowed at 85% of PPS

Exceptions are 100% of PPS for:

  • Laboratory/Pathology services, Injectables or infused drugs including administration, DME and Prosthetics, Radiology services, and Diagnostic tests
 Pharmacist Allowed at 85% of PPS.

Exceptions are 100% of PPS for:

  • Vaccines and administration
 Psychologist Allowed at 85% of PPS

Exceptions are 100% of PPS for:

  • 90785, 90791, 90832, 90834, 90837, 96101 – 96103, 96116, 96118 – 96120, and 96150 – 96155

Note: The existence of a procedure code on this list is not a guarantee that the code is valid or is covered.

Limitations and Exclusions:

While reimbursement is considered, payment determination is subject to, but not limited to:

  • Group or Individual benefit
  • Provider Participation Agreement
  • Routine claim editing logic, including but not limited to incidental or mutually exclusive logic, and medical necessity
  • Mandated or legislative required criteria will always supersede.

In instances where the provider is participating, based on member benefits, co-payment, coinsurance, and/or deductible shall apply.

Reimbursement policies are intended only to establish general guidelines for reimbursement under BCBSND plans. BCBSND retains the right to review and update its reimbursement policy guidelines at its sole discretion.