Policy No: 114
Originally Created: 07/01/2012
Section: Administrative
Last Reviewed: 08/01/2024
Last Revised: 09/01/2022
Approved: 08/08/2024
Effective Date: 09/01/2024
This policy applies to all physicians, other qualified health care professionals, hospitals, and other facilities.
Average Sales Price (ASP) - A statutorily defined price based on actual sales transactions published and maintained by Centers for Medicare & Medicaid Services (CMS) and used for physician administered, infused, and injected drugs.
Medicare Physician Fee Schedule (MPFS) - Document published and maintained by CMS that includes relative value units and other relevant information used in determining professional pricing.
Our health plan uses several Medicare fee schedules for claims pricing. This includes, but is not limited to the Clinical Laboratory Fee Schedule (CLAB) and ASP pricing. In addition, our health plan also utilizes the MPFS as a source of RVU values.
When a current Medicare-based fee is used for a Commercial Product, our health plan will generally use the CMS fee effective date as specified below:
a) New Codes
When a Current Procedural Terminology (CPT®) or Healthcare Common Procedure Coding System (HCPCS) code is issued, our health plan will use the fee or Relative Value Unit (RVU) published by CMS.
b) Existing Codes
For a code that is already established, if there are changes to a CMS fee schedule (i.e., CLAB, ASP) CMS effective date will be used except where provider contract language indicates otherwise.
When a commercial fee schedule methodology and/or fee(s) are frozen during the term of the contract, our health plan will generally use the CMS fee effective date as specified below:
a) New Codes
When a CPT® or HCPCS code is issued, our health plan adjudicates claims using the latest fee or RVU for the original effective date of the new code. CMS may change a fee or RVU to the original effective date on a retroactive basis.
b) Existing Codes
For a code that is already established, no changes to fee or RVU will be made for any CMS updates issued.
Our health plan provides reimbursement for claims in accordance with the date of service of the claim and the applicable fee reflected in our system in effect at the time the claim is processed. Our health plan will update our claims payment system within sixty (60) days of the date on which our vendor releases updates with regards to CMS’s Medicare Prospective Payment System (PPS) and Medicare fee schedules. Claims will not be retroactively adjusted to reflect the updated fees after the system update.
Our health plan reserves the right to set a fee schedule amount for any code, whether that code has a published CMS fee.
None
Your use of this Reimbursement Policy constitutes your agreement to be bound by and comply with the terms and conditions of the Reimbursement Policy Disclaimer.