Highmark Announces
Adjustments to UCR and Premier Blue sm Shield Reimbursement
As noted in the April
2011 issue of PRN, Highmark filed with, and has now received
approval from, the Pennsylvania Insurance Department to implement a
broad range of UCR Level II and Premier Blue Shield
reimbursement adjustments.
The adjustments impact
anesthesia, select surgical, diagnostic and evaluative services, including, but
not limited to, musculoskeletal, eye, behavioral health, allergen immunotherapy
and routine electroencephalography procedures.
• Increases in
allowance will be implemented for dates of service beginning July 1, 2011.
• A minimum number of
allowances will be decreased for dates of service on/after Sept. 26, 2011.
Highmark will also
implement changes to its payment differential for evaluation and management
procedure codes 99201 through 99215 when performed in the facility, compared
to services performed in a non-facility setting. Effective Sept 26, 2011,
Highmark will calculate payment for the facility service using Medicare's
site-of-service differential, or at a predetermined cap, not to exceed a
certain designated percentage. Currently, Highmark applies a 15 percent differential.
In addition, the
allowances for CT studies of the abdomen and pelvis combined, procedure codes
74176, 74177 and 74178,will be increasing with this update. The allowances will be
based upon additional data collection and analysis and have yet to be
finalized.
Fees Available Via
NaviNet
You may access the
reimbursement adjustment information online in four convenient ways.
1. Visit
our Provider Resource Center via NaviNet. Simply hover
on Administrative Reference Materials, and click on Fee
Updates to view the complete list of fee adjustments. (Fees
are not published on the public Provider Resource Center.)
When the adjustments
are in effect (see effective dates above), you can also use the following
online tools.
2. On NaviNet, hover
on Allowance and then select Allowance Inquiry to
determine pricing for specific procedure codes-by planrproduct type.
3. Also on NaviNet,
you can hover on Allowance, and select Frequently
Billed Codes.This function initiates a report request that provides
you with a quicker means of retrieving the most frequently billed
codes/procedure codes based on the specialty represented by the selected
billing provider and plan.
4. Via
NaviNet's Resource Center, you can download the full Premier
Blue Shield fee schedule. Simply click on
Administrative
Reference Materials.
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