The NCCA has received numerous questions and concerns regarding the Aetna SHP fee schedule for S8890. The fee of $26.82 is the National Aetna Market Fee Schedule amount. SHP fees are determined based upon HCPCS Level I (CPT) or Level II codes using the following hierarchy and criteria. 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 S8890 so they utilized 50% of eligible billed charges. There IS a rate for S8890 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.