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

Policy ID: NDRP-MISC 003
Section: Reimbursement
Effective Date: July 01, 2019
Last Reviewed: November 25, 2019

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 Addiction 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.

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.