Medicare-Based Fee Effective Dates - Medicare Advantage

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 Medicare fee schedules for claims pricing. This includes, but is not limited to PFSRVF, Clinical Laboratory Fee Schedule and ASP pricing.

All fees have effective dates. A fee is used when the date of service on a claim line item is on or after the fee effective date.

When a Medicare-based fee is used for a Medicare Advantage product, our health plan will generally use the CMS fee effective date as specified below:

a) New Codes
When a code is newly issued, our health plan will use the fee/Relative Value Unit (RVU) published by CMS prior to the new code's implementation date. Any CMS changes made to the RVU or fee after the code is implemented will be administered using the "Existing Codes" instructions.

b) Existing Codes
Our health plan will always use CMS effective dates for changes to existing codes except where provider contract language indicates otherwise.

Claims will only be adjusted when 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.