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Premier PPO Out of Network Reimbursement Clarification

Aug 21, 2012

Clarification of Anthem Blue Cross Small Group Out of Network Reimbursement on Premier PPO Plans

As recently communicated, Anthem Blue Cross has changed how they reimburse covered services received from out-of-network professional providers(doctors and health providers) for Small Group Premier PPO plans (Premier PPO $10 Copay, Premier PPO $20 Copay and Premier PPO $30 Copay).  They have received  questions from their agent community regarding this change and they want to clarify a few key points.

Small groups renewing on any of the Premier PPO plans will now, in most cases, have claims reimbursed for out-of-network covered services by professional providers based on the FAIR Health fee schedule* instead of using an Ingenix fee schedule.
While there will be some differences between the two fee schedules, Anthem's application of the new schedule has been designed to result in an overall reimbursement level which is comparable to the historical out-of-network reimbursement level of the Premier PPO plans. Among Anthem's small group offerings, the Premier PPO plans will continue to have the highest level of reimbursement for services rendered by out-of-network professional providers.

Comparison to non-Premier PPO Plans
There is an approximate 50% overall reduction in the maximum allowed amount for professional services rendered by out-of network providers from the Premier PPO plan to a non-Premier PPO plan. Here’s an example to show the difference between the maximum allowed amount for Anthem Premier plan versus a non-Premier plan to demonstrate that the Premier plans continue to have the higher reimbursement levels:
Procedure: Professional reading of an MRI/MRA for brain/head/neck (CPT code 70546)
OON Max Allowed for Small Group Premier PPO:  $1,540.75
OON Max Allowed for Small Group Non-Premier PPO:  $737.20

Procedure: Psychiatrist Evaluation (CPT code 90801)
OON Max Allowed for Small Group Premier PPO:  $384.37
OON Max Allowed for Small Group Non-Premier PPO:  $183.91

This information is intended to provide a high level overview of changes and the comparison of Premier and non-Premier PPO plan reimbursements. Anthem Blue Cross reserves the right to periodically update or otherwise modify its fee schedules in accordance with its internal policies and member certificates. If you have any questions regarding these changes, please contact your b&p Group Sales Representative - 888.722.3373.

*The maximum allowed amount is based upon Anthem's Statewide Prudent Buyer Fee Schedule using percentages that will allow the reimbursement to remain budget neutral in Aggregate to the Fair Health based out of network fee schedules.
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