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Professional Fee Schedule
Blue Shield's objective in developing physician and healthcare professional compensation rates is to closely align payments with the resources used by providers for rendering professional services. Therefore, allowances may vary by geographic region.
How Blue Shield Establishes Allowances
In general, Blue Shield uses the Resource Based Relative Value Scale (RBRVS) methodology as a guide for establishing physician and healthcare professional allowances. Clinician input and other established industry resources are also used to validate provider allowances. Like CMS, Blue Shield considers facility-based pricing for some procedures when establishing allowances.
- Tier A indicates Blue Shield's professional fees.
- Tier B designates professional services provided in a facility setting that also have a rate differential.
Immunization allowances are established using the Average Wholesale Price (AWP) as a guide, while injectable drug allowances are set by using a tiered, Average Sales Price (ASP) reimbursement methodology. This methodology promotes the use of cost-effective therapies by paying a greater percentage of costs above the ASP for generic therapies.
Payment determination can be made only after the claim has been received by Blue Shield and reviewed in light of eligibility and medical necessity. Contract limitations/exclusions, Medical Policy, and Claim Check guidelines will also be applied. Blue Shield's allowances are subject to periodic review.
Professional allowances are generally reviewed on an annual basis with Blue Shield giving providers at least 60 days advance notice of any changes in our allowances. Drug and immunization allowances are reviewed quarterly with no advance notice of changes.
Get additional information about Blue Shield's Payment Policies and Rules.