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1.Primary Care services (E&M and Surgical CPT codes) for Assigned Beneficiaries: 110% of the Medicare Payment Rate as a base rate.
2. Primary Care services for Non-Assigned Beneficiaries: 100% of the Medicare Payment Rate
3. Laboratory Services: 90% of the Medicare Payment Rate (Provider Physician will make every effort to use PLAN's preferred lab vendor(s).
4. All other services, including radiology and HCPCS, including reimbursement for Specialists: 100% of the Medicare Payment Rate.
5. Unlisted Procedures: Procedures not listed, or procedures with relatives not established and which are otherwise Covered Services, Provider will be compensated 70% of billed charges.

By receipt of this Fee Schedule/Rate Information, you acknowledge and agree that (1) the enclosed information is strictly confidential and proprietary; and (2) you will not distribute or disclose this information to any third party. Any unauthorized review, use, disclosure or distribution is prohibited.


This schedule is not a guaranty of payment. Variances in reimbursement may occur due to rounding calculations. Services represented are subject to provisions of the health plan including, but not limited to, membership, eligibility, premium payment, claim payment logic, provider contract terms and conditions, applicable medical policy, and benefits, limitations and exclusions.  Maximum allowables and components of rates such as modifiers or conversion factors, and applicable rules such as bundling, may change from time to time subject to notice requirements of applicable law and regulation and the prevailing provider agreement.  Values reflect the component of a code related to the place of treatment. CPT codes are copyright American Medical Association.  All Rights Reserved.


To download and/or print a PDF version of this information, click below.

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