Site of Service for Professional Reimbursement

BCBSNE has implemented professional reimbursement based on site of service. BCBSNE will determine the rate to pay (facility or non-facility rate) for covered services provided by a participating professional based on the place of service (POS) code. This POS code is used to identify the setting in which the patient received the face-to-face encounter with the physician, non-physician practitioner (NPP) or other supplier.

Professional claims will be reimbursed according to facility allowances when they are submitted with POS codes 19, 21, 22, 23, 24, 31, 51, 53 or 61. All other covered professional services will continue to be reimbursed according to non-facility allowances.

Not all procedure codes will have a facility allowance. In some instances, BCBSNE may choose not to use a facility allowance that the Centers for Medicare and Medicaid Services (CMS) identifies for a procedure code. The non-facility and facility allowances that will be applicable to BCBSNE professional claims will be identified in BCBSNE’s fee schedules.