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.
2009 Overseas Fee Schedule
| Proceedure | Fee |
|---|---|
| Bone Density Study (77080) | $231.00 |
| Cesarean Delivery (routine ante and postpartum care) (59510) | $5,039.00 |
| Chest X-ray (two views frontal and lateral) (71020) | $104.00 |
| Circumcision, clamp, procedure; newborn (54150) | $296.00 |
| Colonoscopy, Flexible, proximal diagnostic (45378) | $1,081.00 |
| CT Scan, Head or Brain; with contrast (70470) | $699.00 |
| Electrocardiogram (with interpretation and report) (93000) | $79.00 |
| Extracapsular Cataract Removal with Insert Intraocular (66984) | $3,481.00* |
| Individual Psychotherapy (45-50 minutes, psychiatrist) (90806) | $170.00 |
| Initial Hospital Care (comprehensive) (99223) | $315.00 |
| Office/Other Outpatient Visit (for established patient, minimal) (99211) | $57.00 |
| Physical Therapy Evaluation (97001) | $108.00 |
| Physical Therapy-therapeutic procedure 1 or more areas, 15 min each (97110) | $43.50 |
| Prostate Specific Antigen (PSA) (84153) | $93.00 |
| Repair Inguinal Hernia (age 5/over, reducible) (49505) | $1,672.00* |
| Routine Obstetrical Care (delivery, pre and postnatal care) (59400) | $5,039.00 |
| Screening Mammography (bilateral) (77057) | $165.00 |
| Sigmoidoscopy (flexible, diagnostic) (45330) | $351.00 |
| Tonsillectomy, Adenoidectomy age 12 and over (42821) | $1,465.00* |
| Tonsillectomy, Adenoidectomy under age 12 (42820) | $1,221.00* |
| Total Hysterectomy (with or without removal of tubes/ovaries) (58150) | $4,871.00* |
| Well Child Care, Periodic Comprehensive Exam (under age 1) (99391) | $122.00 |