The Regence Fee Schedule
The Regence Fee Schedule lists the fees that apply to most providers in the Regence BlueShield network. It does not include all procedure codes and prices for all network providers. The Regence Fee Schedule and other pricing information are subject to change and will be updated regularly.
Regence network providers should reference the specific terms of their Provider Agreement for fee schedule information, or contact a Regence BlueShield Provider Consultant to confirm fee schedule information.
Payment based on the Regence Fee Schedule is subject to all of the terms and conditions of the applicable Regence provider agreement, member benefits, Regence policies, and all published Regence administrative guidelines. The fact that fees are listed for particular procedure codes does not guarantee coverage.
Uniform Medical Plan (UMP) provider information
Regence providers, please visit Regence's UMP webpage for information about:
- Products and networks
- Identifying members (includes sample member ID cards)
- Claims and billing information (includes link to UMP Clinical Edits by Code List)
- Washington State Health Technology (HTCC) assessments
- Customer service
UMP clinical opioid policy
Starting January 2, 2018, the UMP clinical opioid policy limits the number of opioids that UMP will cover for members. This policy is a tool to prevent misuse and addiction, a chance to promote safe prescribing practices, and a direct response to Governor Jay Inslee’s executive order to combat the opioid crisis.
These limits do not apply to members who are:
- Already receiving ongoing opioids therapy (meaning they have filled at least one opioid prescription per month in three of the last four months).
- Receiving cancer treatment.
- In hospice care, palliative care, or end-of-life care.
Additionally, use of opioids for more than 42 days may be authorized in 12 month intervals when the prescriber signs the Chronic Opioid Attestation form. If a prescriber wants an attestation to be authorized for less than 12 months, the prescriber can include a specific end date on the attestation form. Read the UMP clinical opioid policy for more information about this attestation form.
If you or your patients have questions, these resources may help:
- One-page flyer about the UMP clinical opioid policy
- Getthefactsrx.com, an HCA-funded awareness campaign about the dangers of prescription drug misuse
- Washington State Rx Services Customer Service, 1-888-361-1611 (TRS: 711)
Joining a UMP Plus network
If you are a provider interested in joining a UMP Plus network, follow the instructions below.
How providers are paid
UMP currently contracts with Regence to provide a professional provider network. UMP pays providers a percentage of the Regence allowed amount for covered services and supplies under the plan. The percentage paid depends on the provider’s network status: preferred (network for UMP Plus), participating, or out-of-network. The member pays the remainder of the allowed amount. If the member sees an out-of-network provider, the member will pay the remainder of the allowed amount plus the balance billed amount.
For preferred (network for UMP Plus) and participating providers, the allowed amount is what the providers contractually agree to accept as payment in full for a service or supply. Preferred (network for UMP Plus) and participating providers cannot balance bill members.
For out-of-network providers who are not accessed through the BlueCard Program, the allowed amount is an amount Regence determines to be reasonable charges for covered services or supplies. Regence may base the allowed amount on the billed charges for some services, an amount determined by Regence, or an amount as otherwise required by law.
For out-of-network providers accessed through the BlueCard Program, the allowed amount is the lower of the provider's billed charges and the amount that the on-site BlueCross and/or Blue Shield organization identifies to Regence as the amount on which it would base a payment to that provider.
Out-of-network providers can balance bill members.
Hospitals and other facilities
Network hospitals are paid according to a method called “Medicare Severity Diagnosis Related Groups” (MSDRG). When a patient is admitted to a hospital, he or she is assigned a primary diagnosis (for example, diabetes, pneumonia, or fractured leg). Each primary diagnosis is associated with a group called a “diagnosis related group.” UMP pays the hospital a certain amount for treatment associated with that diagnosis related group.
There may be times when the amount a hospital billed is higher or lower than the set amount paid because the plan does not take into account whether patients in a diagnosis related group need more or less treatment than average.
UMP may pay a hospital separately for procedures that don’t fall under the MSDRG treatment plan.
Regence has engaged with key provider groups to establish incentive programs that reward these provider groups for providing cost-effective, high-quality care. UMP and Regence do not use incentive programs or penalties to encourage providers to withhold services or avoid referrals to specialists.
Quality Improvement Program
A few provider groups have Quality Improvement (QIP) agreements with Regence. These provider groups can earn a higher level of reimbursement (a rate increase above the negotiated rate) if they meet one or more QIP targets. The targets are usually related to one or more of the following:
- Increased rate of generic prescriptions
- Reduced unnecessary emergency room utilization
- Reduced hospital readmission rate (readmissions that occur within 30 days of a prior discharge)
- Reduced C-section rate