Our first group customer selects Reference Based Benefits feature for certain member segments

Last month, we told you about a new benefit feature that some of our large, national customers are looking at — Reference Based Benefits, or RBB. This new feature encourages members to use online tools to help compare the costs of certain services and also establishes a reference price for those services.

As of our publication date, there’s one customer that has selected this feature for some of its members — syncreon. The group number, segment, alpha prefix and other key information will be included in The Record’s billing chart next month. However, we wanted to take this opportunity to remind you about working with RBB for Blue Cross Blue Shield of Michigan members.

How do I identify a member with RBB?

For syncreon, members will be identified with group number 71316. Additionally, a special message will appear on web-DENIS when you look up a member’s benefits and eligibility. The message will tell you that the contract includes Reference Based Benefits.

Where can I get information about the member liability?

For more information about the member liability for a given service, go to web-DENIS and check your patient’s benefits and eligibility. Once you enter the member’s ZIP code and select a treatment category, you’ll see the associated RBB information, including the reference price. As we explained in last month’s Record, the member is responsible for their usual cost share plus any difference between the reference price and the allowed amount for the service if the allowed amount exceeds the reference price.

Note: Keep in mind that this feature affects member cost share, not what health care providers will charge for services. In-network providers can expect to receive contracted rates on all procedures.

What services does this apply to?

For syncreon, the customer has decided to apply Reference Based Benefits to services such as:

• Hip and knee replacement (inpatient)
• Shoulder arthroscopy, upper GI endoscopy, sigmoidoscopy (outpatient)
• MRIs, CT scans and ultrasounds (diagnostic radiology)

A full list of applicable services is posted on web-DENIS in the Benefits and Eligibility section.

How does RBB work?

For planned, non-emergent services, members will access an online cost transparency tool to search for providers and compare the estimated costs for those services. When they receive services from providers at costs below the reference price, reference pricing will not apply. Blue Cross will continue to pay the allowed amount, and the member will be responsible for their usual cost share. For services with a cost that exceeds the reference price, Blue Cross will pay up to the reference price, and the member is responsible for any difference between the reference price and the allowed amount of the service, plus their usual cost share.

For example: If a reference price is $500 for an MRI of the spine and the allowed amount is $700, then Blue Cross pays up to $500 for the procedure. The member is responsible for their standard cost share on the $500, plus the $200 difference between the allowed amount and the reference price.

For more information, see the presentation on web-DENIS, which will be available by Dec. 1:

• Log in to web-DENIS.
• Click on BCBSM Provider Publications and Resources.
• Click on Newsletter and Resources.
• It will be in the “What’s New” section of the page.