The NCCA has received numerous questions and concerns regarding the Aetna SHP fee schedule for S8990. The NCCA verified with the SHP that it is a covered code. Many have asked why the fee schedule is different and how Aetna can not follow the 50% of eligible billed charges structure that BCBS utilized. This is due to contracted hierarchy and criteria between Aetna & the SHP. The first of the following criteria that can be used to establish a price will be the applicable source:
- Designated percentage of current NC Medicare Part B Physician Fee Schedule
- IF NOT AVAILABLE – 100% of National Aetna Market Fee Schedule.
- IF NOT AVAILABLE – 50% of the 80th percentile of the Usual & Prevailing profile.
- IF NOT AVAILABLE – 50% of eligible billed charges.
So in a nutshell – Under BCBS there was not a BCBS Market Fee or Prevailing profile for S8990 so they utilized 50% of eligible billed charges. There IS a rate for S8990 under National Aetna Market Fee Schedule and according to the SHP contract, that is the rate to be utilized. NCCA is reaching out to ChiroCongress to discuss steps to petition for an increase. We will continue to look for more opportunities to impact the fee schedule.