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.
Reduction Reason
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Description
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Certified Diabetic Educator
Licensed Registered Dietician
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Allowed at 85% of PPS
Exceptions are 100% of PPS for:
- 98960 – 98962, G0108, G0109, and S9145
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Chiropractor
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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.
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Certified Registered Nurse Anesthetist
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Allowed at 85% of PPS for non-anesthesia services
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Clinical Nurse Specialist
Nurse Midwife
Nurse Practitioner
Physician Assistant
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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
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Licensed Addiction Counselor
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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
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Licensed Clinical Social Worker
Licensed Marriage Family Therapist
Licensed Professional Clinical Counselor
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Allowed at 75% of PPS
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Licensed Master Social Worker
Licensed Professional Counselor
Naturopath
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Allowed at 50% of PPS
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Local Public Health Unit
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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
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Pharmacist
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Allowed at 85% of PPS.
Exceptions are 100% of PPS for:
- Vaccines and administration
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Psychologist
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Allowed at 85% of PPS.
Exceptions are 100% of PPS for
- 90785, 90791, 90832, 90834, 90837, 96116, 96156-96171
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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.
Revision Date
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History
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6/8/2020
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- 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
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