Introducing Reference Based Pricing

November 29, 2012

Employers continue to seek alternative approaches to help take more control of health care expenses, some of which include placing a greater emphasis on employee accountability in making health care decisions. Employers have been offered a new benefit - Reference Based Pricing – which limits certain benefits for specified procedures to a specific dollar amount. With Reference Based Pricing, the benefit maximum – called the reference cost – is predetermined for a selection of individual non-emergency outpatient procedures.

You may begin to see Blue Cross and Blue Shield of Oklahoma (BCBSOK) members and out-of-area Blue Cross and Blue Shield (BCBS) members who belong to employer groups with Reference Based Pricing as early as Jan. 1, 2013.

To determine if Reference Based Pricing applies to your patient, you should check eligibility and benefits as you normally would – via an electronic transaction through your preferred vendor, or by utilizing the BCBSOK interactive voice response system. For out-of-area members, you may contact the BlueCard® Eligibility Line at 800-676-2583. There is nothing you will need to do differently when filing claims.

Watch for further information in the Blue Review.

Verification of eligibility and/or benefit information is not a guarantee of payment. Benefits will be determined once a claim is received and will be based upon, among other things, the member’s eligibility, any claims received during the interim period and the terms of the member’s certificate of coverage applicable on the date services were rendered.