3417 73rd Street, Suite T Lubbock, Texas 79423
806-785-0590 FAX 806-785-5488
Payor List September 2013
ADVANTAGE TEAM CHOICE – Effective January 1, 2005
Karen Sawyer 806-795-5959
140% Current Year Lubbock RBRVS (Medicare) for E&M CPT Codes
165% Current Year Lubbock RBRVS (Medicare) for all other CPT Codes
150% Current Year Lubbock RBRVS (Medicare) for Laboratory Services
Anesthesia $50/unit
AETNA – Effective July 15, 2005
Angie Rogers 830-620-0977
Fees based on Current Lubbock RBRVS
150% for E&M CPT codes (90780-99602)
185% for Surgical CPT codes (10021-69990)
150% for Lab and Pathology CPT codes (80048 – 88400)
150% for Radiology CPT codes (70010 – 79999)
120% for HCPCS J codes (J0120 – J9999); (A0021 – H2037); (K0001 – S9881); (S9986 – V5364)
All other services not otherwise identified – 100% of Aetna Market Fee Schedule
Anesthesia $55 / unit
AETNA MEDICARE ADVANTAGE AMENDMENT – Effective August 1, 2010
Angie Rogers 830-620-0977
Covered Services will be reimbursed at 100% of the current Rest of Texas RBRVS Based Fee Schedule
AMERIGROUP – Effective March 1, 2012
Timothy Salinas 806-748-4880
100% of Current Year Medicare Fee Schedule for Professional Services
50% of Current Year Medicare Fee Schedule for Clinical Lab Services
60% of Current Year Medicare Fee Schedule for Durable Medical Equipment
100% of Current Year Medicare Fee Schedule for Drugs and Biologicals
Medicaid and CHIP: 100% of Current Year Medicaid Fee Schedule
BLUE CROSS BLUE SHIELD – Effective December 15, 2003
Lupe Rocha 806-783-4610
Contract and All fee schedules on the Southwest Medical IPA website: www.swmipa.com
CAPSTAR – Effective March 1, 2012
Maria Aguilar 806-783-9995
Fees based on Current Year RBRVS
175% Surgery Codes (10000 – 69999)
150% Radiology Codes (70000 – 7999)
150% Pathology Codes (80000 – 89999)
130% Medicine / E&M Codes (90000 – 99999)
120% HCPCS Codes
Anesthesia $62 / unit
HUMANA CHOICE CARE – Effective January 21, 2011
Chrissy Perkins 512-851-6002
Primary Care 135% ChoiceCare 005-795 Schedule (except for Drugs & Biologicals and Lab Services)
Specialists 180% ChoiceCare 005-795 Schedule (except for Drugs & Biologicals and Lab Services)
Anesthesia $65.00 per unit
Physician Extenders, Podiatrists 85% ChoiceCare 005-795 Schedule (except for Drugs & Biologicals and Lab Services)
Drugs and Biologicals 100% ChoiceCare 201-544 Schedule
In-Office Lab Services 100% ChoiceCare 005-795 Schedule (all other labs paid at 0%)
Any service/code not listed above 100% ChoiceCare 005-795 Schedule
This agreement also includes participation in ChoiceCare’s Medicare Advantage network. Reimbursement for services provided to Medicare Advantage members is as follows:
Physicians 100% ChoiceCare 005-795 Schedule
Physician Extenders 85% ChoiceCare 005-795 Schedule
ChoiceCare’s 005-795 fee schedule is based on the Medicare Resource Based Relative Value Scale. Choice Care’s 005-795 fee schedule is available on the IPA’s website (www.swmipa.com). The in-office allowed lab list is attached to this messenger and is also available on the IPA’s website. ChoiceCare schedule 201-544 for Drugs and Biologicals is available on the IPA’s website.
CIGNA – (includes Great West) – Effective August 1, 2010
Katrina Ventre 972-863-5468
Fee Schedules and Contract on the IPA’s website (www.swmipa.com)
FIRSTCARE – Effective April 1, 2000
Stephanie Dumas 806-784-4312
Fee Schedules and Contract on the IPA’s website (www.swmipa.com
FIRSTCARE Value Network Plan – Effective July 1, 2013
Fees in accordance with the FirstCare HMO fee schedule
Fee Schedules and Contract on the IPA’s website (www.swmipa.com)
GALAXY – Effective April 15, 2003
Mary Woods
Reimbursement 90% of billed charges
HEALTHSMART – Effective August 15, 2001
Chrystal Scott 214-574-2374
Codes ranging from 99201 – 99400: 135% of Current RBRVS, locality 99
All other codes: 185% of Current RBRVS, locality
Any code not listed in the fee schedule will revert to 20% off Provider’s billed charges
Anesthesia $52 / unit
HealthSmart Network for Workers’ Compensation/Occupational Injuries:
90% of Texas Worker’s Compensation Fee Schedule
HEALTHSPRING (Medicare Advantage Plan)– Effective December 1, 2009
Sarah Clark 806-236-6750
Reimbursement to participating Primary Care Physician shall be 105% of the current year’s Medicare RBRVS Allowable Fee Schedule. Primary Care Physician (“PCP”) means a Participating Provider who is a General Practice, Family Practice, Pediatric, Internal Medicine, or other Physician designated by HealthSpring to provide Primary Care Services to Members pursuant to a Participating Provider agreement with HealthSpring.
Reimbursement to participating Specialist Physician shall be 100% of the current year’s Medicare RBRVS Allowable Fee Schedule.
Laboratory CPT Codes (80000 – 89999) - Labs are to be sent to Quest with the exception of CPT codes included on the in office lab list (Attachment 1). In office labs will be reimbursed at 100% of current Medicare RBRVS. All other labs not sent to Quest will be reimbursed at 80% of current Medicare RBRVS.
Imaging CPT codes (70000 – 79999) – In office imaging will be reimbursed according to contract at 105% of current Medicare to PCPs and 100% of current Medicare to Specialists.
HCPCS Codes – HCPCS codes will be reimbursed according to contract at 105% of current Medicare to PCPs and 100% of current Medicare to Specialists.
MULTIPLAN (includes Beechstreet, PHCS, and Texas True Choice)– Effective November 1, 2011
Contract on the IPA’s website (www.swmipa.com)
Contract Rates Exhibit D pp. 15 – 17
OMNI – Effective September 1, 2002
Jorgann Lane 806-373-5944
135% of 2001 Medicare RBRVS Fee Schedule for CPT Codes (99201 – 99499)
200% of 2001 Medicare RBRVS Fee Schedule for CPT Codes (10040 – 89999)
Anesthesia $50 / unit
PRIME HEALTH SERVICES – Effective January 1, 2012
Lindsay Hardin 615-565-8229
130% of Medicare for all codes with a Medicare Allowed Amount
75% of Billed Charges for unlisted codes