Pricing Methodology

Reimbursement rates for HME, supplies, procedures, orthotics/prosthetics and medications identified by National Level II HCPCS codes will be the lesser of the following rate-setting methodologies:

• Published Medicare payment rates for those HME, supplies and orthotics/prosthetics that have a Medicare rate.
• When the item does not have a rate or is an unlisted code that is not for a drug/biologic, it is priced using the manufacturer’s cost invoice. Payment will be based on suggested retail price less a 15% discount or the provider’s acquisition cost plus 35%, whichever is less. Purchase orders are not an acceptable substitute for an invoice. 
• A separately implemented fee schedule is utilized for drugs and biologicals. Payment for these items, including but not limited to the “J” code series of the Level II HCPCS codes, is updated quarterly. 
• Adjustments to these payment values will be made quarterly. Drugs and biologicals that do not have a specific Level II HCPCS code and associated reimbursement amount will be reimbursed at Average Wholesale Price (AWP) based on the National Drug Code (NDC) number for the product. Claims submitted for drugs and biologicals that do not have a specific Level II HCPCS code must include the specific drug name and associated NDC number, dosage/units administered and the associated charge.
• When an injectable dosage given is greater than the HCPCS Level II code definition, use the units field to specify the appropriate number of units.
  • Example: The patient received 8 mg of haloperidol.  The common dosage for haloperidol (J1630) is “up to 5 mg.” Two units of service (UOS) should be submitted. The dosage is rounded up to the next unit.
• Professional 837P charges for therapeutic, prophylactic or diagnostic injections when rendered in certain places of service are not payable. Professional services (837P) submitted with a facility place of service (such as 21, 22 or 23) will deny as provider liability.  
• Any unclassified drug must include the drug name, dosage and 11-digit NDC.
• Fee schedule allowances may also be adjusted using market analysis of charges submitted by providers for like procedures, a relative value scale that compares the complexity of services provided or any other factor Blue Cross and Blue Shield of Nebraska (BCBSNE) deems necessary.
• BCBSNE allows 85% of the cost for custom orthotics manufactured by the provider. If not custom made and a manufacturer invoice is supplied, the reimbursement is 135% of invoice cost or billed charge, whichever is the lesser of.

When the Centers for Medicare & Medicaid Services does not set a rate for a piece of equipment, BCBSNE will need the cost invoice to price the claim. Purchase orders are not an acceptable substitute for an invoice. All claims are paid according to the member’s contract.

Providers may ask for a reconsideration of the reimbursement level of a submitted charge and must supply all data necessary for BCBSNE to decide appropriate reimbursement. In all cases, BCBSNE will make a final determination of reimbursement level based upon the criteria detailed above. The covered person is not responsible for payment of disputed charges during the reconsideration process. The provider may not bill the covered person for any payment under dispute.