Reimbursement Calculations

The Blue Cross and Blue Shield of New Mexico (BCBSNM) maximum allowable fee schedule uses certain aspects of the Medicare Resource Based Relative Value System (RBRVS) methodology. 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 , as well as flat fees 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 2013 American Medical Association (AMA). All rights reserved. CPT is a registered trademark of the AMA.