Blue Cross and Blue Shield Service Benefit Plan.
2007 Overseas Fee Schedule.
The Washington, DC Plan processes overseas claims at Preferred levels based on an Overseas Fee Schedule (OFS). Members are responsible for the difference between the Plan's payment and the provider's charge. The Plan's payment is based on a very specific and detailed list of procedures. Listed below are examples of those procedures and their corresponding OFS reimbursement levels. These are examples only. This is by no means a comprehensive list of all types of procedures and their corresponding levels. This listing does not represent pre-authorization, nor is it a guarantee of benefits. Each claim is reviewed on its own merit, and the reimbursement level is based on all the pertinent medical information submitted with the claim.
Bone Density Study, the Plan's payment is $296.00.
Cesarean Delivery (routine ante and postpartum care), the Plan's payment is $4,570.00.
Chest X-ray (two views frontal and lateral), the Plan's payment is $94.00.
Circumcision, clamp, procedure; newborn, the Plan's payment is $267.00.
Colonoscopy, Flexible, proximal diagnostic, the Plan's payment is $980.00.
CT Scan, Head or Brain; with contrast, the Plan's payment is $633.00.
Electrocardiogram (with interpretation and report), the Plan's payment is $71.00.
Extracapsular Cataract Removal with Insert Intraocular Prosthesis, the Plan's payment is $3,157.00. (Please note that the reimbursement levels for all surgical procedures include pre- and post-operative care.)
Individual Psychotherapy (45-50 minutes, psychiatrist), the Plan's payment is $153.00.
Initial Hospital Care (comprehensive), the Plan's payment is $285.00.
Office/Other Outpatient Visit (for established patient, minimal), the Plan's payment is $51.00.
Physical Therapy Evaluation, Initial, the Plan's payment is $97.00.
Physical Therapy-therapeutic procedure 1 or more areas, 15 min each, the Plan's payment is $39.00.
Prostate Specific Antigen (PSA), the Plan's payment is $83.00
Repair Inguinal Hernia (age 5/over, reducible), the Plan's payment is $1,516.00. (Please note that the reimbursement levels for all surgical procedures include pre- and post-operative care.)
Routine Obstetrical Care (delivery, pre and postnatal care), the Plan's payment is $4,570.00.
Screening Mammography (bilateral), the Plan's payment is $159.00.
Sigmoidoscopy (flexible, diagnostic), the Plan's payment is $318.00.
Tonsillectomy, Adenoidectomy age 12 and over, the Plan's payment is $1,328.00. (Please note that the reimbursement levels for all surgical procedures include pre- and post-operative care.)
Tonsillectomy, Adenoidectomy under age 12, the Plan's payment is $1,106.00. (Please note that the reimbursement levels for all surgical procedures include pre- and post-operative care.)
Total Hysterectomy (with or without removal of tubes/ovaries), the Plan's payment is $4,418.00. (Please note that the reimbursement levels for all surgical procedures include pre- and post-operative care.)
Well Child Care, Periodic Comprehensive Exam (under age 1), the Plan's payment is $110.00.