Reimbursement and Fee Schedules
These policies apply to all NMHC plan products. The member’s contracted health plan benefits must be in effect on the date that services are rendered. NMHC reserves the right to review and update our Reimbursement Policies periodically.
NMHC typically reimburses its providers based on the current CMS Medicare fee schedule; however, we may negotiate other reimbursement based on NMHC or provider needs. We may adopt reimbursement or methodology changes required by CMS guidance or federal or state laws/regulations, and we may incorporate annual CMS increases or decreases to the fee schedule. Although we primarily use the CMS fee schedule, we occasionally may process claims outside of the standardized CMS payment logic.
The primary fee schedules are:
- CMS Inpatient Prospective Services (IPPS)
- CMS Outpatient Prospective Services (OPPS)
- Physician Fee Schedule (MPFS)
- Durable medical equipment, prosthetics and orthotics, and supplies (DMEPOS)
- CMS Clinical Laboratory Fee Schedule
- CMS Average Sales Price (ASP)
- Home Health PPS
- Hospice PPS
- Other applicable CMS fee schedules
To calculate your reimbursement, go to the easy-to-use CMS lookup tool: https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PFSlookup/index.html.
This link will open in a new window. Enter a CPT or HCPCS code to calculate 100 percent of reimbursement. Be sure to apply your contracted allowable percentage, if applicable.
In all cases, it is NMHC’s policy to reimburse providers the lesser of the provider’s billed charge or the provider’s contracted reimbursement rate.
Reimbursement of Covered Non-Contracted Goods and Services
It is NMHC’s policy to reimburse, rather than to deny claims payment to, contracted network providers when the provider submits claims for goods or services without a negotiated provision for those specific goods and services within the provider’s contract with NMHC.
Reimbursement is contingent on the goods or services being a covered benefit, and contingent on the provider following NMHC guidelines for obtaining health plan authorization for the good or service, or providing the appropriate notification to the health plan prior to the service rendered. Providers must also treat members within their scope of practice specialty. The following are a few examples of covered non-contracted goods or services:
- Durable Medical Equipment (DME) (goods) issued to a member without a negotiated DME provision within the provider’s contract with NMHC.
- Infusion drugs (goods and/or services) administered to a member without a negotiated provision for drugs or “J” codes within the provider’s contract with NMHC.
- Lab tests drawn and/or tested by provider or provider’s lab with no negotiated lab provision within the provider’s contract with NMHC.
While NMHC is not a CMS entity, NMHC will utilize the lesser of the provider’s billed charge, or CMS’s reimbursement methodology and fee schedules, to administer usual and customary payment for covered non-contracted goods and services.
The following are examples of, but not limited to, the fee schedules NMHC uses use to administer payment of covered non-contracted goods and services:
- CMS DMEPOS: Durable Medical Equipment and Prosthetics and Orthotics
- CMS ASP: Drugs, Infusion, Injectables
- CMS CLFS: Clinical Laboratory Fee Schedule
Facility “Overhead” Reimbursement Policy
While NMHC may utilize Medicare fee schedules and CMS methodology to adjudicating claims, NMHC is not a Medicare entity, and does not recognize or reimburse Facility Overhead Charges.
A Facility Overhead Charge is a clinic charge for any technical component or overhead that is billed by a facility when a professional provider renders covered services to NMHC members in a facility clinic setting.
NMHC defines a facility clinic visit as a preventive, curative, diagnostic, rehabilitative, and/or education service provided to an ambulatory patient in an outpatient setting, whether in a freestanding or attached facility that is either owned, operated, leased, or controlled by the facility.
Some examples of a facility clinic visit include, but are not limited to a member:
- Having blood drawn for lab work at a facility draw station
- Seeing a behavioral health provider on a hospital campus
- Getting an X-ray at a diagnostic center
- Seeing his or her PCP
- Receiving education from a nutritionist
NMHC reimburses professional providers for covered services provided in a facility clinic setting when filed on a CMS-1500 form with place of service codes to include, but not limited to, place of service 11, 20, or 22 (Office, Urgent Care, Outpatient). This reimbursement will always include both the professional services and the associated overhead.
NMHC will not separately reimburse a facility for facility clinic visits and services billed on a UB-04, or any other form, when reported with revenue codes 510-525, 527-529 and any successor codes, including but not limited to the accompanying G Codes.
The technical and overhead component of the facility clinic visit will be included by NMHC in the reimbursement paid to the professional provider for professional services, as reported on the CMS-1500 form, with place of service codes to include, but not limited to, place of service 11, 20, or 22. These services may encompass but are not limited to Evaluation and Management health care services provided to NMHC members in a clinic setting.
The facility may not seek reimbursement for any technical or overhead component of the clinic charge from NMHC or from our members. The member is held harmless and may not be balance-billed by the provider for clinic facility charges.
In accordance with the terms of your Agreement with NMHC, we reserve the right to recover overpayments resulting from separately billed clinic/facility fees billed in combination with a professional office/clinic visit claim.