Reimbursement Calculations

The Blue Cross and Blue Shield of New Mexico (BCBSNM) maximum allowable fee schedule utilizes certain aspects of the Medicare Resource Based Relative Value System (RBRVS) methodology. BCBSNM recently evaluated the 2016 RBRVS Relative Value Units (RVUs). As a result, effective for dates of service on and after Sep. 1, 2016, BCBSNM made the decision to update its Maximum Allowable Fee Schedule by making certain adjustments to the 2016 RBRVS RVUs and fees while generally maintaining their relativity. New codes will continue to be added to the system and pricing for injectable drugs will be updated quarterly.

Therefore, for dates of service on and after Sep. 1, 2016, your reimbursement will no longer be calculated using the March 2010 RVUs that were effective for BCBSNM on Jul. 1, 2010, but rather, BCBSNM’s updated Maximum Allowable Fee Schedule as described above.

To evaluate the changes in your reimbursement that may result from BCBSNM’s updated Maximum Allowable Fee Schedule, you may receive an interactive copy of the Schedule by emailing your request to FeeScheduleRequests@bcbsnm.com. Please be sure to reference be sure to reference “Request for Interactive BCBSNM Maximum Allowable Fee Schedule” in the subject line and include your Tax ID in the message body. The Schedule is confidential and proprietary information and must be maintained as such per your Agreement. BCBSNM values your participation in our programs and welcomes your input. If you have any questions or concerns, contact the Network Services Department at (505) 837-8800 or (800) 567-8540 for assistance.

For dates of service prior to Sep 1, 2016 - 2010 Reimbursement Calculations.
BCBSNM traditionally updated the maximum allowable fee schedule to the current year RBRVS relative value units (RVUs).

BCBSNM evaluated the Centers for Medicare & Medicaid Services (CMS) decision to implement a decrease in the RBRVS conversion factor with a concurrent increase to certain RVUs and has made the decision not to convert to the 2011 CMS RVUs and flat fees. New codes continue to be added to the system and the average sale price for injectable drugs will be updated quarterly, if applicable.

Current reimbursement rates continue to be calculated using the 2010 RVUs that became effective July 1, 2010 and contractual conversion factors remain as specified in your current Medical Services Entity Agreement. Recognizing there may be certain aspects of your contracted reimbursement that are not RBRVS based, those components will remain unaffected.

As a result, the March 2010 RVUs currently being used are no longer available on the CMS website. To assist, providers can view our current RBRVS RVUs for facility and non-facility PDF Document , as well as flat fees PDF Document for services such as clinical laboratory and durable medical equipment.

To get the fee for the RBRVS-based Current Procedural Terminology (CPT®) code, multiply the unit value by your contract agreement conversion factor which can be found on the reimbursement attachment.

The fees derived are not a guarantee of payment. Services represented are subject to provisions of the health plan including, but not limited to: membership, eligibility, premium payment, claim payment logic, provider contract terms and conditions, applicable medical policy, benefit limitations and exclusions, bundling logic, and licensing scope of practice limitations. Maximum allowable may change from time to time subject to notice requirements of applicable law and regulations and prevailing provider agreement.

CPT Copyright 2016 American Medical Association (AMA). All rights reserved. CPT® is a registered trademark of the AMA.