Qualified Healthcare Provider’s Allowed Amount Reductions

Policy ID: NDRP-MISC-003

Section: Miscellaneous

Effective Date: July 01, 2019

Revision Effective Date: July 01, 2024

Last Reviewed: May 01, 2024

Applies To: Commercial and Medicaid Expansion

Description

Blue Cross Blue Shield North Dakota (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. The below information applies to both Commercial and Medicaid Expansion lines of business, unless otherwise specified.

Reduction Reason

Description

Certified Diabetic Educator (CDE)

Allowed at 75% of PPS
Exceptions are 100% of PPS for:

97802-97804, 98960 – 98962, G0108, G0109, and S9145

Certified Registered Nurse Anesthetist (CRNA)

Allowed at 85% of PPS for non-anesthesia services

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.
74263, 76706, 77063 and 77067

Clinical Nurse Specialist (CNS)

Allowed at 85% of PPS
Exceptions are 100% of PPS for:

Laboratory/Pathology services, Blood and Blood products, Injectables or infused drugs including administration, DME and Prosthetics, Radiology services, and Diagnostic tests
74263, 76706, 77063, 77067, 99002, H0020, H2010, J0585-J0588, J2503, J2545, J3396, J7308, J7330, Q2026, Q2028, S0190 and S0191

Nurse Midwife (CNM)

Allowed at 85% of PPS
Exceptions are 100% of PPS for:

Laboratory/Pathology services, Blood and Blood products, Injectables or infused drugs including administration, DME and Prosthetics, Radiology services, and Diagnostic tests
74263, 76706, 77063, 77067, 98960-98962, 99002, G0108, G0109, J0585-J0588, J2503, J2545, J3396, J7308, J7330, Q2026, Q2028, S0190 and S0191

Nurse Practitioner (NP)
Physician Assistant (PA)

Allowed at 85% of PPS
Exceptions are 100% of PPS for:

Laboratory/Pathology services, Blood and Blood products, Injectables or infused drugs including administration, DME and Prosthetics, Radiology services, and Diagnostic tests
74263, 76706, 77063, 77067, 98960-98962, 99002, G0108, G0109, H0020, H2010, J0585-J0588, J2503, J2545, J3396, J7308, J7330, Q2026, Q2028, S0190, S0191 and S9145

Licensed Addiction Counselor (LAC)

Allowed at 75% of PPS
Exceptions are 100% of PPS for:

Laboratory/Pathology services
H0004, H0005, H0020, H2010, H2019 and H2035
For Medicaid Expansion: H0002, H0031, H2011, H2014 and H2017

Exceptions are 50% of PPS for

90791, 90832, 90834, 90837, 90839, 90840 and H0001

Licensed Clinical Social Worker (LCSW)
Licensed Professional Clinical Counselor (LPCC)

Allowed at 75% of PPS
Exceptions are 100% of PPS for : H0020, H2010, H2019
Exceptions are 100% of PPS for Medicaid Expansion:

H0002, H0004, H0031, H2011, H2014 and H2017

Licensed Marriage Family Therapist (LMFT)

Allowed at 75% of PPS for

90785, 90791, 90832, 90834, 90837, 90839, 90840, 90846, 90847, 90853 and H0001

Licensed Master Social Worker (LMSW)
Licensed Professional Counselor (LPC)

Allowed at 65% of PPS
Exceptions are 100% of PPS for: H0020, H2010, H2019
Exceptions are 100% of PPS for Medicaid Expansion:

H0002, H0004, H0031, H2011, H2014 and H2017

Licensed Registered Dietician (LRD)

Allowed at 75% of PPS
Exceptions are 100% of PPS for:
97802-97804, 98960 – 98962, G0108, G0109, and S9470

Local Public Health Unit (LPHU)

Allowed at 75% of PPS
Exceptions are 100% of PPS for:

Laboratory/Pathology services, Blood and Blood products, Injectables or infused drugs including administration, DME and Prosthetics, Radiology services, and Diagnostic tests
74263, 76706, 77063, 77067, J0585-J0588, J2503, J2545, J3396, J7308, J7330, Q2026, Q2028, S0190 and S0191

Naturopath

Allowed at 65% of PPS

Peer Support Specialist

Allowed at 100% of PPS for H0038

Pharmacist

Allowed at 85% of PPS.
Exceptions are 100% of PPS for:

Vaccines and administration

Psychologist (PhD)

Allowed at 85% of PPS.
Exceptions are 100% of PPS for (as defined in the CPT/HCPCS codebook)

Psychiatry codes (except for 90867-90870; 90880-90885; 90899)
Health Behavior Assessment and Intervention
Development/Behavioral Screening and Testing
Psychological/Neuropsychological Testing
Adaptive Behavior Assessments/Treatments
Psychiatric Collaboration Care Management
Alcohol and Drug Abuse Treatment Services (Hxxxx HCPCS) (except for H0031, H0033, H0041-H0045, H2012, H2014-H2016, H2021-H2031, H2034, H2035)
Additional codes may or may not be reduced based on diagnosis code billed and/or benefit categorization.

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

Policy Application

All claims submitted for this policy will be processed according to the policy effective date and associated revision effective dates in effect on the date of service.

Limitations & 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, payment integrity edits 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.

History

Date

Updates

6/8/2020

Removed deleted codes from policy.
- 96101-9603 termed 1/1/2019
- 96118-96120 termed 1/1/2019
- 96150-96155 termed 1/1/2020
Added new codes 96156-96171

6/24/2021

Updated QHP Allowed amounts for the following provider specialties:

a. Certified Diabetic Educator (CDE)- from 85% to 75% of the PPS rate. Added codes 97802-97804 to the list of codes at 100% of PPS.
b. Licensed Addiction Counselor (LAC)- added H0001 to list of codes at 50% of PPS rate.
c. Licensed Registered Dietitian (LRD) – from 85% to 75% of the PPS rate. Added codes 97802-97804 to the list of codes at 100% of PPS.
d. Licensed Marriage Family Therapist (LMFT)- added H0001 to list of codes at 75% of PPS rate.
e. Licensed Master Social Worker (LMSW) – from 50% to 65% of the PPS rate.
f. Licensed Professional Counselor (LPC) – from 50% to 65% of the PPS rate
g. Local Public Health Unit (LPHU) – from 85% to 75% of PPS rate.
h. Naturopaths – from 50% to 65% of the PPS rate
i. Psychologist- added H0001 to list of codes at 100% of PPS rate.

4/28/2022

Added section for Peer Support Specialist.

6/20/2022

Add CPT codes that would allow at 100% of PPS for the Medicaid Expansion product for LMSW, LPC and Psychologist.

8/23/2023

Added further information regarding allowing at 100% of PPS for the Medicaid Expansion product for Licensed Addiction Counselor, Licensed Clinical Social Worker and Licensed Professional Clinical Counselor. Backdating these updates to 7/1/2023.

7/1/2024

Added information regarding allowing H2019 at 100% of PPS for Commercial product for LAC, LCSW, LPCC, LMSW and LPC; backdating this update to 5/1/2024

Added clarification regarding items that are allowed at 100% of PPS for Psychologist

For 7/1/24 update:

Added Blood and Blood Products as allowing at 100% of PPS for CNS, CNM, NP, PA and LPHU.
Added MOUD codes (H0020 & H2010) to allow at 100% of PPS for CNS, NP, PA, LAC, LCSW, LPCC, LMSW and LPC

Disclaimer

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.

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Qualified Healthcare Provider’s Allowed Amount Reductions

Description

Reduction Reason

Description

Policy Application

Limitations & Exclusions

History

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