Sept. 25, 2024
We are aware of providers or groups filing claims under the rendering National Provider Identifier of a physician or medical doctor when services were actually performed by a mid-level provider, resulting in claims being paid at inflated reimbursement rates.
As a reminder, reimbursement is based on the type of rendering provider indicated on the claim. The provider types listed below will have the differentials applied to the Schedule of Maximum Allowances as noted:
100% of the SMA
Physician
85% of the SMA
- Licensed Clinical Psychologist
- Certified Nurse Specialist
- Certified Nurse Practitioner
- Certified Registered Nurse Anesthetist
- Licensed Physician Assistant
85% of 20% of the SMA
- Licensed Surgical Assistant
- Registered Nurse First Assistants
70% of the SMA
- Licensed Clinical Social Worker
- Master Social Worker
- Licensed Clinical Professional Counselor
- Licensed Professional Counselor
- Licensed Marriage and Family Therapist
- Board Certified Behavioral Analyst
- Board Certified Assistant Behavioral Analyst
- Certified Early Intervention Specialist
- Developmental Therapist
Please review your billing practices and ensure claims submitted to Blue Cross of Blue Shield Illinois are in compliance with requirements specified in our Provider Manual and your provider agreement.
If you’re aware of an instance of potential fraud, waste or abuse, we encourage you to file a report online or call our Fraud Hotline at 877-272-9741 to create a report. All online reports and calls are confidential, and you may remain anonymous. For more information, visit our Fraud and Abuse page.