Description:
This policy is established to address clear lines of responsibility for the establishment of pricing of services.   It will provide a structure for rapid determination of reimbursement levels for various covered services as well as recognize the unique capabilities of Professional Reimbursement and the Corporate Medical Staff.

Policy Statement:
When there is no pricing available for professional services, regardless of the line of business, claims should be forwarded to the appropriate support department for the establishment of allowances. Claims should be handled as follows:

• Professional Reimbursement:  

     Durable Medical Equipment
     X-ray and Laboratory Services
     Supplies
     Drug allowances
     Diagnostic Medical Care

• PSMM Nurse Reviewers:

Surgical allowances, including but not limited to non-listed procedures, that are not addressed by established payment methodology tables or fee schedules.

           Anesthesia
           Assistant at Surgery

Bluecard ITS Home/Control Plan Claims:
The allowance from the Host Plan’s participating provider received on the submission format (SF) should always be accepted.  This allowance will supersede any negotiated rates that have been established by the Managed Care area.  Utilizing negotiated rates, rather than using the Host Plan’s allowance, allows for balance billing by the provider to the member.

Calls received from a non-participating provider where negotiated rates have been established should be instructed to file directly to the South Carolina BlueCard program in order to have the negotiated rates applied.  A deferral (D5B46) should be loaded to the system to ensure proper adjudication of the claim.  

If a call is received from an out of state provider that indicates he/she is non-participating, rates can be documented and approved.  IF, however, the claim filed is from a participating physician, all negotiated rates are null and void. Pricing from the SF record received from the other plan will be utilized for reimbursement.

Note: The Case-Specific Rate Negotiations Inter-Plan Programs and Provisions must be followed if and when negotiating on an out-of-state non-participating provider ITS Home claim.

BlueCard ITS Host And Local Claims:
When there is not pricing available for covered professional services, and the charge is $50.00 or less, the charge may be allowed without verification from Professional Reimbursement or Retro Review Nurses.