CurrentBlue Cross Blue Shield - North CarolinaPolicy CMS030.0053

Out-of-Network Fee Schedules

Defines methodology, timing, and responsible parties for developing and maintaining out-of-network (OON) fee schedules for Commercial, FEP, and SHP lines of business in North Carolina.

Policy Summary

PayerBlue Cross Blue Shield - North Carolina

PolicyOut-of-Network Fee Schedules

Policy CodePolicy CMS030.0053

Change TypeNo material change

Effective DateJan 1, 2025

Next Review DateJul 1, 202620d

Key ActionDevelop fee schedule and forward to Director, Network Pricing & Expense Analysis for approval, then to Manager, Provider Network Pricing & Expense Analysis for implementation.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

Annualtypical update cycle

QPA Annuallysurprise-billing update

Statewide Fee Schedulereimbursement basis (some types)

100% peer avgstandard allowed amount

Out-of-Network Allowed Amount Criteria

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

OON Allowed Amount Criteria

Allowed amount determination by provider type.

Hospital - Non-Surprise Billing: Allowed amount determined by peer-group calculations; Inpatient = Peer Group Total Inpatient Allowed / Peer Group Total Inpatient Billed; Outpatient = Peer Group Total Outpatient Allowed / Peer Group Total Outpatient Billed; Update cycle: Annually (January).

Hospital - Surprise Billing: Allowed amount determined by Qualifying Payment Amount (QPA) fee schedule (QPA defined as the fee schedule generally based on the median contracted rate in the same insurance market, similar provider specialty, and geographic region); Update cycle: QPA Annually (January).

Physician/Professional - Non-Surprise Billing: Allowed amount = 100% of current year non-facility negotiable pricing sources and standard non-negotiable rate; Update cycle: Annually (April).

Physician/Professional - Surprise Billing: Allowed amount determined by Qualifying Payment Amount (QPA) fee schedule; Update cycle: QPA Annually (January).

Ambulatory Surgery Center: Allowed amount set to Statewide Fee Schedule; Update cycle: Annually (January).

Dialysis Facility: Allowed amount based on Statewide Fee Schedule (peer group bundled average inclusive of hemodialysis, labs, supplies, drugs); labs/drugs payable outside bundle per base lab/drug fee schedules as applicable.

Reference Laboratory: Allowed amount set to Statewide Fee Schedule.

Home Health: Allowed amount = Statewide average allowed per day (determine average allowed per day for peer group and set OON to 100% of peer group average where specified); annual updates per policy.

Home Infusion Therapy: Allowed amount set to Statewide Fee Schedule.

Private Duty Nursing: Allowed amount = Statewide average allowed per service (determine peer group average allowed per service and set OON to 100% of peer group average where specified).

Home Durable Medical Equipment: Allowed amount set to Statewide Fee Schedule.

Skilled Nursing Facility: Allowed amount set to Statewide average allowed per bundled service.

Residential Mental Health & Substance Abuse: Allowed amount set to Statewide Fee Schedule.

Lithotripsy Services: Identify all in-network non-hospital lithotripsy providers (peer group), determine average allowed per procedure, and set OON allowed amount to 100% of the peer group average.

Birth Center Services: Allowed amount set to Statewide average allowed per service.

Licensed Dietitian Nutritionist Services: Allowed amount set to Statewide Fee Schedule.

Opioid Treatment Programs: Allowed amount = 100% of current year NC Medicare MLN for OTP locality (bundled/outpatient).

Hospice Service: Not currently administered due to administrative considerations.

Specialty Pharmacy Services: Not applicable (NA) under this policy.

General rule: Manager, Network Pricing and Expense Analysis loads pricing for impacted providers after the responsible party develops the fee schedule and it is approved by Director Network Pricing and Expense Analysis and then implemented by the Manager.

Coding and Payment Level

Coding scopemixed

No specific CPT/HCPCS/ICD codes specified in this policy; pricing approaches reference fee schedules, statewide fee schedules, peer group averages, and QPA.

Payment level

Typical payment levelTypically set to 100% of peer group average or 100% of statewide fee schedule depending on provider type

Examples using 100% of peer group averageLithotripsy Services, Home Health, Private Duty Nursing — set OON allowed amount to 100% of peer group average per procedure/day/service

Examples using Statewide Fee ScheduleReference Laboratory, Home Infusion Therapy, Home Durable Medical Equipment — use Statewide Fee Schedule as the allowed amount

Physician/Professional (non-surprise)100% of current year non-facility negotiable pricing sources and standard non-negotiable rate

Approval and Implementation Workflow

Documentation Required

Approval and Implementation Workflow — Develop, Approve, Implement Fee Schedule

The responsible party must develop the fee schedule (pursuant to the methodology listed in this policy) and forward it to the Director, Network Pricing & Expense Analysis for approval, and then to the Manager, Provider Network Pricing & Expense Analysis for implementation.

Develop fee schedule using the methodology specified for each provider type (e.g., peer group totals, QPA, statewide fee schedule, or 100% of peer group/Statewide fee as applicable).
Forward the completed fee schedule to the Director, Network Pricing & Expense Analysis for approval.
After Director approval, forward to the Manager, Provider Network Pricing & Expense Analysis for implementation.

Key Definitions

OON fee schedules — methodology & timing

Policy purposeTo develop, implement and maintain Out-Of-Network (OON) fee schedules consistent with Plan benefit certificates

Scope (timing & applicability)Documents methodology and timing for OON fee schedules for Commercial, FEP, and SHP product lines in North Carolina

Procedure & responsible partiesResponsible party develops the fee schedule and forwards to Director Network Pricing and Expense Analysis for approval, then to Manager Provider Network Pricing & Expense Analysis for implementation

Provider-specific scheduling examplesCertain provider types use annual updates (e.g., hospitals/physicians) or use Statewide Fee Schedule as noted in provider criteria

Qualifying Payment Amount (QPA)

QPA definitionQualifying Payment Amount (QPA) is a fee schedule generally based on the median contracted rate provided in the same insurance market, similar provider specialty, and in the same geographic region

Use casesApplied as the calculation methodology for Surprise Billing hospital and physician allowed amounts

Relative roleServes as the basis for OON allowed amounts where policy specifies QPA for surprise-billing situations