July 2018

Update to Default Rate for CPT^®/HCPCS Codes on the Illinois Medicaid Fee Schedule with No Specified Rate

Beginning on July 20, 2018, Blue Cross and Blue Shield of Illinois (BCBSIL) will implement a new reimbursement methodology for Healthcare Common Procedure Coding System (HCPCS) and Current Procedural Terminology (CPT) codes found on the Illinois Department of Healthcare and Family Services (HFS) fee schedules with no specified rate. The CPT/HCPCS codes fitting these criteria will default to a two-tiered reimbursement method.

Unless otherwise noted, the tiered structure will be as follows:

• Tier One – Centers for Medicare & Medicaid Services (CMS) Medicare rate
• Tier Two – 25 percent of billed charges
  

If a CPT/HCPCS code is on the HFS fee schedule with no attached rate, BCBSIL will first reimburse according to the CMS Medicare rate for the applicable submitted claims. If there is no associated Medicare rate, BCBSIL will reimburse 25 percent of the billed charges for applicable submitted claims.

If you have any questions regarding the Illinois Medicaid Fee Schedule, please contact your BCBSIL Provider Network Consultant (PNC).

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