Medicare-Based Fee Effective Dates

Policy No: 114
Originally Created: 07/01/2012
Section: Administrative
Last Reviewed: 06/01/2019
Last Revised: 06/01/2017
Approved: 06/06/2019
Effective Date: 07/01/2019

This policy applies to all physicians, other qualified health care professionals, hospitals and other facilities.

Definitions

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.

Physician Fee Schedule Relative Value File (PFSRVF)
Document published and maintained by CMS that includes relative value units and other relevant information used in determining professional pricing.

Policy statement

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 PFSRVF as a source of RVU values.

When a Medicare-based fee is used for a non-Medicare Advantage 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 newly issued, our health plan will use the fee or Relative Value Unit (RVU) published by CMS, if available.

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 always be used except where provider contract language indicates otherwise.

The RVU value for existing codes will not be changed except in cases wehre CMS has notified Payers that a correction has been made.

Both of these scenarios could result in a retroactive effective date. Our health plan will only adjust claims as required by CMS.

References

None

Disclaimer

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.