Customer detail

ECP

183
live contracts
8
cannot fire
23
calc types
4
SQL bodies
1
of those blocked
4
map conflicts

Methodology mix

ModifierAdjustment2,483
FlatFee235
LesserOfAdjustment188
MedicareMultipleEndoscopyAdjustment188
MedicareMultipleRadiologyAdjustment188
MidLevelProviderAdjustment188
ChargeLevelSqlAdjustment188
MedicareMultipleProcedureAdjustment186
MedicareBilateralSurgeryAdjustment184
PercentOfFees179
MedicareDrug123
FlatPercentOfCharges112
MedicareRVU108
MedicareLab71
MedicareDME69
MedicareMultipleOphthalmologyAdjustment49
MedicareASC35
MultipleSurgeryAdjustment31
CalculationBuilder16
CaseRate8
PercentOfCharges5
SqlExpression3
ExcludedChargeAdjustment1

Contracts

Each is one fee logic. Base terms are first-match-wins; adjustments all apply, in order. Expand to see the terms.

100% Grouper Facility Fees2 base · 20 adj
United Healthcare
Facility · StPetersburgASC · 2023-01-01 → 2999-12-31
BCBS Commercial Plans, BCBS HMO, BCBS PPO
Facility · StPetersburgASC · 2023-01-01 → 2999-12-31
BCBS Commercial Plans, BCBS HMO, BCBS PPO
Facility · LargoASC · 2023-01-01 → 2999-12-31
United Healthcare
Facility · PRECISION_VISION · 2023-01-01 → 2999-12-31
United Healthcare
Facility · LargoASC · 2023-01-01 → 2999-12-31
Base terms — first match wins
  1. flat $0 — when NoncoverageStatus Noncovered is present
  2. 100% of the Facility-Fees fee schedule
Adjustments — all apply, in order
  1. multiple-surgery reduction (contract rules) — pays 100/50%
  2. Medicare multiple-endoscopy reduction
  3. Medicare multiple-radiology reduction — base codes 4
  4. Medicare bilateral-surgery adjustment
  5. mid-level provider reduction (by NUCC taxonomy)
  6. modifier 22 present → 135% of the running amount
  7. modifier 52 present → 50% of the running amount
  8. custom SQL — Same global-surgery post-op allocation as hash c5fd5754fcf4a52d (Allowed/GlobalDays*PostOpRate), but hardened: falls back to returning {Allowed} unchanged when GLOB_DAYS or POST_OP is missing/non-numeric/zero instead of dividing by zero. — when Modifier 55 is present
  9. modifier 54 present → 80% of the running amount
  10. modifier 62 present → 62.5% of the running amount
  11. modifier 73 present → 50% of the running amount
  12. modifier 78 present → 70% of the running amount
  13. modifier 80 present → 16% of the running amount
  14. modifier 81 present → 16% of the running amount
  15. modifier 82 present → 16% of the running amount
  16. modifier AS present → 14% of the running amount
  17. modifier QY present → 50% of the running amount
  18. modifier QK present → 50% of the running amount
  19. modifier QX present → 50% of the running amount
  20. cap each charge and the account total at 100% of billed charges
100% Medicare 50% Lab7 base · 20 adj
Humana Medicare
Profee · CVP_MIDATLANTIC, RIV · 2023-01-01 → 2999-12-31
Humana Medicare
Profee · ASSOCIATED_RETINAL · 2023-01-01 → 2999-12-31
Humana Medicare
Profee · BSV_EyeClinicMichigan · 2023-01-01 → 2999-12-31
Humana Medicare
Profee · BSV_TukelEye · 2023-01-01 → 2999-12-31
Humana Medicare
Profee · BYRD_AND_WYAN · 2023-01-01 → 2999-12-31
Humana Medicare
Profee · SOUTHGATE · 2023-01-01 → 2999-12-31
Humana Medicare
Profee · AVC_ALABAMA · 2023-01-01 → 2999-12-31
Humana Medicare
Profee · TUSCALOOSA · 2023-01-01 → 2999-12-31
Humana Medicare
Profee · PADUCAH · 2024-05-01 → 2999-12-31
Humana Medicare
Profee · CVP_MIDWEST, NOVUS, RS_OHIO · 2024-01-01 → 2999-12-31
Humana Medicare
Profee · RAK · 2024-05-01 → 2999-12-31
Base terms — first match wins
  1. flat $0 — when NoncoverageStatus Noncovered is present
  2. 50% of Medicare lab
  3. 100% of Medicare drug
  4. 75% of Medicare DME ⚠︎ named “100% of Medicare DME” but configured at 75%
  5. 100% of Medicare RVU — when PlaceOfService 2 is present
  6. 100% of Medicare RVU
  7. 0% of billed charges
Adjustments — all apply, in order
  1. Medicare multiple-endoscopy reduction
  2. Medicare multiple-radiology reduction — base codes 4
  3. Medicare bilateral-surgery adjustment
  4. Medicare multiple-procedure reduction — base codes 2, 3; pays 100/50% — when Modifier 55 is absent; Modifier 82 is absent
  5. mid-level provider reduction (by NUCC taxonomy)
  6. modifier 22 present → 135% of the running amount
  7. modifier 52 present → 50% of the running amount
  8. modifier 54 present → 80% of the running amount
  9. custom SQL — Same global-surgery post-op allocation as hash c5fd5754fcf4a52d (Allowed/GlobalDays*PostOpRate), but hardened: falls back to returning {Allowed} unchanged when GLOB_DAYS or POST_OP is missing/non-numeric/zero instead of dividing by zero. — when Modifier 55 is present
  10. modifier 62 present → 62.5% of the running amount
  11. modifier 73 present → 50% of the running amount
  12. modifier 78 present → 70% of the running amount
  13. modifier 80 present → 16% of the running amount
  14. modifier 81 present → 16% of the running amount
  15. modifier 82 present → 16% of the running amount
  16. modifier AS present → 14% of the running amount
  17. modifier QY present → 50% of the running amount
  18. modifier QK present → 50% of the running amount
  19. modifier QX present → 50% of the running amount
  20. cap each charge and the account total at 100% of billed charges
100% Medicare Rates No Sequestration7 base · 20 adj
Caresource
Profee · RAK · 2021-01-01 → 2999-12-31
Molina
Profee · ASSOCIATED_RETINAL · 2023-01-01 → 2999-12-31
Molina Exchange
Profee · BSV_EyeClinicMichigan · 2023-01-01 → 2999-12-31
BayCare
Profee · LargoASC · 2023-01-01 → 2999-12-31
Amerihealth
Profee · Monmouth · 2023-01-01 → 2999-12-31
Clover Health
Profee · Monmouth · 2023-01-01 → 2999-12-31
BayCare
Profee · StPetersburgASC · 2023-01-01 → 2999-12-31
Cigna
Profee · StPetersburgASC · 2023-01-01 → 2999-12-31
Molina, Molina Exchange
Profee · WalkerSurgeryCenter · 2023-01-01 → 2999-12-31
BCBS KS
Profee · GRENE_VISION · 2023-01-01 → 2999-12-31
Cigna
Profee · LargoASC · 2023-01-01 → 2024-05-31
Paramount
Profee · CVP_MIDWEST, NOVUS, RS_OHIO · 2023-01-01 → 2999-12-31
Oscar
Profee · CVP_MIDATLANTIC · 2023-01-01 → 2999-12-31
Piedmont Community Health Marketplace
Profee · CVP_MIDATLANTIC · 2023-01-01 → 2999-12-31
Humana
Profee · ARIZONA_EYE · 2023-01-01 → 2999-12-31
Wellcare
Profee · AVC_ALABAMA · 2023-01-01 → 2999-12-31
BCBS KS
Profee · STILES · 2023-01-01 → 2999-12-31
Tricare
Profee · OPHC_NEXTGEN · 2024-01-01 → 2999-12-31
Essence
Profee · QUANTUM · 2023-01-01 → 2999-12-31
Contigo
Profee · ECP_NEXTGEN, OK · 2023-01-01 → 2999-12-31
Trinity
Profee · SurgicalCareCenterMI · 2023-01-01 → 2999-12-31
Trinity
Profee · WalkerSurgeryCenter · 2023-01-01 → 2999-12-31
Tricare
Profee · SurgicalCareCenterMI · 2023-01-01 → 2999-12-31
Base terms — first match wins
  1. flat $0 — when NoncoverageStatus Noncovered is present
  2. 100% of Medicare lab
  3. 100% of Medicare drug
  4. 100% of Medicare DME
  5. 100% of Medicare RVU — when PlaceOfService 2 is present
  6. 100% of Medicare RVU
  7. 0% of billed charges
Adjustments — all apply, in order
  1. Medicare multiple-endoscopy reduction
  2. Medicare multiple-radiology reduction — base codes 4
  3. Medicare bilateral-surgery adjustment
  4. Medicare multiple-procedure reduction — base codes 2, 3; pays 100/50% — when Modifier 55 is absent; Modifier 82 is absent
  5. mid-level provider reduction (by NUCC taxonomy)
  6. modifier 22 present → 135% of the running amount
  7. modifier 52 present → 50% of the running amount
  8. modifier 54 present → 80% of the running amount
  9. custom SQL — Same global-surgery post-op allocation as hash c5fd5754fcf4a52d (Allowed/GlobalDays*PostOpRate), but hardened: falls back to returning {Allowed} unchanged when GLOB_DAYS or POST_OP is missing/non-numeric/zero instead of dividing by zero. — when Modifier 55 is present
  10. modifier 62 present → 62.5% of the running amount
  11. modifier 73 present → 50% of the running amount
  12. modifier 78 present → 70% of the running amount
  13. modifier 80 present → 16% of the running amount
  14. modifier 81 present → 16% of the running amount
  15. modifier 82 present → 16% of the running amount
  16. modifier AS present → 14% of the running amount
  17. modifier QY present → 50% of the running amount
  18. modifier QK present → 50% of the running amount
  19. modifier QX present → 50% of the running amount
  20. cap each charge and the account total at 100% of billed charges
100% Profee Fees Schedule3 base · 20 adj
Molina Marketplace OH
Profee · CVP_MIDWEST, NOVUS, RS_OHIO · 2023-01-01 → 2999-12-31
Priority Health
Profee · ASSOCIATED_RETINAL · 2023-01-01 → 2999-12-31
Cigna
Profee · PANHANDLE · 2023-01-01 → 2999-12-31
Humana
Profee · GRENE_VISION · 2022-01-01 → 2999-12-31
Tricare
Profee · CVP_MIDATLANTIC · 2023-01-01 → 2099-12-31
BCBS KS
Profee · CAVANAUGH · 2023-01-01 → 2999-12-31
Humana
Profee · QUANTUM · 2023-01-01 → 2999-12-31
Humana
Profee · CAVANAUGH · 2023-01-01 → 2999-12-31
Cigna
Profee · SABATES_EYE · 2018-05-01 → 2999-12-31
Anthem Commercial Plans, Anthem HMO, Anthem PPO
Profee · PADUCAH · 2023-01-01 → 2024-10-31
Cigna
Profee · ECP_NEXTGEN, OK · 2023-01-01 → 2999-12-31
BCBS Blue Preferred, BCBS Blue Traditional, BCBS Commercial Plans
Profee · ECP_NEXTGEN, OK · 2024-01-01 → 2999-12-31
Humana
Profee · EyePhysiciansPinellas · 2023-01-01 → 2999-12-31
United Healthcare
Profee · EyePhysiciansPinellas · 2023-01-01 → 2999-12-31
Base terms — first match wins
  1. flat $0 — when NoncoverageStatus Noncovered is present
  2. 100% of Medicare drug
  3. 100% of the Profee-Fees fee schedule
Adjustments — all apply, in order
  1. Medicare multiple-procedure reduction — base codes 2, 3; pays 100/50% — when Modifier 55 is absent; Modifier 82 is absent
  2. Medicare multiple-endoscopy reduction
  3. Medicare multiple-radiology reduction — base codes 4
  4. Medicare bilateral-surgery adjustment
  5. mid-level provider reduction (by NUCC taxonomy)
  6. modifier 22 present → 135% of the running amount
  7. modifier 52 present → 50% of the running amount
  8. custom SQL — Same global-surgery post-op allocation as hash c5fd5754fcf4a52d (Allowed/GlobalDays*PostOpRate), but hardened: falls back to returning {Allowed} unchanged when GLOB_DAYS or POST_OP is missing/non-numeric/zero instead of dividing by zero. — when Modifier 55 is present
  9. modifier 54 present → 80% of the running amount
  10. modifier 62 present → 62.5% of the running amount
  11. modifier 73 present → 50% of the running amount
  12. modifier 78 present → 70% of the running amount
  13. modifier 80 present → 16% of the running amount
  14. modifier 81 present → 16% of the running amount
  15. modifier 82 present → 16% of the running amount
  16. modifier AS present → 14% of the running amount
  17. modifier QY present → 50% of the running amount
  18. modifier QK present → 50% of the running amount
  19. modifier QX present → 50% of the running amount
  20. cap each charge and the account total at 100% of billed charges
100% Profee Fees Schedule3 base · 20 adj
United Healthcare Medicare
Profee · EyePhysiciansPinellas · 2023-01-01 → 2999-12-31
BCBS Blue Choice
Profee · ECP_NEXTGEN, OK · 2024-01-01 → 2999-12-31
Base terms — first match wins
  1. flat $0 — when NoncoverageStatus Noncovered is present
  2. 100% of Medicare drug
  3. 100% of the Profee-Fees fee schedule
Adjustments — all apply, in order
  1. Medicare multiple-procedure reduction — base codes 2, 3; pays 100/50% — when Modifier 55 is absent; Modifier 82 is absent
  2. Medicare multiple-endoscopy reduction
  3. Medicare multiple-radiology reduction — base codes 4
  4. Medicare bilateral-surgery adjustment
  5. mid-level provider reduction (by NUCC taxonomy)
  6. modifier 22 present → 135% of the running amount
  7. modifier 52 present → 50% of the running amount
  8. custom SQL — Same global-surgery post-op allocation as hash c5fd5754fcf4a52d (Allowed/GlobalDays*PostOpRate), but hardened: falls back to returning {Allowed} unchanged when GLOB_DAYS or POST_OP is missing/non-numeric/zero instead of dividing by zero. — when Modifier 55 is present
  9. modifier 54 present → 80% of the running amount
  10. modifier 62 present → 62.5% of the running amount
  11. modifier 73 present → 50% of the running amount
  12. modifier 78 present → 70% of the running amount
  13. modifier 80 present → 16% of the running amount
  14. modifier 81 present → 16% of the running amount
  15. modifier 82 present → 16% of the running amount
  16. modifier AS present → 14% of the running amount
  17. modifier QY present → 50% of the running amount
  18. modifier QK present → 50% of the running amount
  19. modifier QX present → 50% of the running amount
  20. cap each charge and the account total at 100% of billed charges
100% Profee Fees Schedule - Ophthalmology Adj - AETNA3 base · 21 adj
Aetna
Profee · GRENE_VISION · 2022-01-01 → 2099-12-31
Aetna
Profee · OPHC_NEXTGEN · 2023-01-01 → 2999-12-31
Aetna
Profee · CAVANAUGH · 2023-01-01 → 2999-12-31
Aetna
Profee · CVP_MIDATLANTIC, RIV · 2023-01-01 → 2999-12-31
Aetna
Profee · CVP_MIDWEST, NOVUS, RS_OHIO · 2023-01-01 → 2999-12-31
Base terms — first match wins
  1. flat $0 — when NoncoverageStatus Noncovered is present
  2. 100% of Medicare drug
  3. 100% of the Profee-Fees fee schedule
Adjustments — all apply, in order
  1. Medicare multiple-procedure reduction — base codes 2, 3; pays 100/50/25% — when Modifier 55 is absent; Modifier 82 is absent
  2. Medicare multiple-ophthalmology reduction — base codes 7; pays 100/80%
  3. Medicare multiple-endoscopy reduction
  4. Medicare multiple-radiology reduction — base codes 4
  5. Medicare bilateral-surgery adjustment
  6. mid-level provider reduction (by NUCC taxonomy)
  7. modifier 22 present → 135% of the running amount
  8. modifier 52 present → 50% of the running amount
  9. custom SQL — Same global-surgery post-op allocation as hash c5fd5754fcf4a52d (Allowed/GlobalDays*PostOpRate), but hardened: falls back to returning {Allowed} unchanged when GLOB_DAYS or POST_OP is missing/non-numeric/zero instead of dividing by zero. — when Modifier 55 is present
  10. modifier 54 present → 80% of the running amount
  11. modifier 62 present → 62.5% of the running amount
  12. modifier 73 present → 50% of the running amount
  13. modifier 78 present → 70% of the running amount
  14. modifier 80 present → 16% of the running amount
  15. modifier 81 present → 16% of the running amount
  16. modifier 82 present → 16% of the running amount
  17. modifier AS present → 14% of the running amount
  18. modifier QY present → 50% of the running amount
  19. modifier QK present → 50% of the running amount
  20. modifier QX present → 50% of the running amount
  21. cap each charge and the account total at 100% of billed charges
100% Profee Fees Schedule - UHC3 base · 22 adj
United Healthcare
Profee · PANHANDLE · 2023-01-01 → 2999-12-31
United Healthcare
Profee · GRENE_VISION · 2022-01-01 → 2999-12-31
United Healthcare
Profee · BYRD_AND_WYAN · 2024-01-01 → 2999-12-31
United Healthcare
Profee · MCPEAK · 2023-01-01 → 2999-12-31
United Healthcare
Profee · OPHC_NEXTGEN · 2022-09-01 → 2999-12-31
United Healthcare
Profee · HOLCOMB · 2023-01-01 → 2999-12-31
United Healthcare
Profee · TUSCALOOSA · 2023-01-01 → 2999-12-31
United Healthcare
Profee · PADUCAH · 2023-01-01 → 2999-12-31
United Healthcare
Profee · ECP_NEXTGEN, OK · 2024-01-01 → 2999-12-31
Base terms — first match wins
  1. flat $0 — when NoncoverageStatus Noncovered is present
  2. 100% of Medicare drug
  3. 100% of the Profee-Fees fee schedule
Adjustments — all apply, in order
  1. Medicare multiple-procedure reduction — base codes 2, 3; pays 100/50% — when Modifier 55 is absent; Modifier 82 is absent
  2. Medicare multiple-endoscopy reduction
  3. Medicare multiple-radiology reduction — base codes 4
  4. Medicare bilateral-surgery adjustment
  5. mid-level provider reduction (by NUCC taxonomy)
  6. modifier 22 present → 135% of the running amount
  7. modifier 53 present → 25% of the running amount
  8. modifier 52 present → 50% of the running amount
  9. custom SQL — Same global-surgery post-op allocation as hash c5fd5754fcf4a52d (Allowed/GlobalDays*PostOpRate), but hardened: falls back to returning {Allowed} unchanged when GLOB_DAYS or POST_OP is missing/non-numeric/zero instead of dividing by zero. — when Modifier 55 is present
  10. modifier 54 present → 80% of the running amount
  11. modifier 62 present → 62.5% of the running amount
  12. modifier 73 present → 50% of the running amount
  13. modifier 78 present → 70% of the running amount
  14. modifier 80 present → 16% of the running amount
  15. modifier 81 present → 16% of the running amount
  16. modifier 82 present → 16% of the running amount
  17. modifier AS present → 14% of the running amount
  18. modifier QY present → 50% of the running amount
  19. modifier QK present → 50% of the running amount
  20. modifier QX present → 50% of the running amount
  21. modifier QZ present → 85% of the running amount
  22. cap each charge and the account total at 100% of billed charges
100% Profee Fees Schedule - UHC Seq3 base · 21 adj
United Healthcare Medicare
Profee · PANHANDLE · 2023-01-01 → 2999-12-31
United Healthcare Medicare
Profee · MCPEAK · 2023-01-01 → 2999-12-31
United Healthcare Medicare
Profee · KENYON_ASC_NEXTGEN, KENYON_NEXTGEN · 2023-01-01 → 2999-12-31
United Healthcare Medicare
Profee · HOLCOMB · 2023-01-01 → 2999-12-31
United Healthcare Medicare
Profee · TUSCALOOSA · 2023-01-01 → 2999-12-31
United Healthcare Medicare
Profee · PADUCAH · 2023-01-01 → 2999-12-31
United Healthcare Medicare
Profee · ECP_NEXTGEN, OK · 2024-01-01 → 2999-12-31
Base terms — first match wins
  1. flat $0 — when NoncoverageStatus Noncovered is present
  2. 100% of Medicare drug
  3. 100% of the Profee-Fees fee schedule
Adjustments — all apply, in order
  1. Medicare multiple-procedure reduction — base codes 2, 3; pays 100/50% — when Modifier 55 is absent; Modifier 82 is absent
  2. Medicare multiple-endoscopy reduction
  3. Medicare multiple-radiology reduction — base codes 4
  4. Medicare bilateral-surgery adjustment
  5. mid-level provider reduction (by NUCC taxonomy)
  6. modifier 22 present → 135% of the running amount
  7. modifier 53 present → 25% of the running amount
  8. modifier 52 present → 50% of the running amount
  9. custom SQL — Same global-surgery post-op allocation as hash c5fd5754fcf4a52d (Allowed/GlobalDays*PostOpRate), but hardened: falls back to returning {Allowed} unchanged when GLOB_DAYS or POST_OP is missing/non-numeric/zero instead of dividing by zero. — when Modifier 55 is present
  10. modifier 54 present → 80% of the running amount
  11. modifier 62 present → 62.5% of the running amount
  12. modifier 73 present → 50% of the running amount
  13. modifier 78 present → 70% of the running amount
  14. modifier 80 present → 16% of the running amount
  15. modifier 81 present → 16% of the running amount
  16. modifier 82 present → 16% of the running amount
  17. modifier AS present → 14% of the running amount
  18. modifier QY present → 50% of the running amount
  19. modifier QK present → 50% of the running amount
  20. modifier QX present → 50% of the running amount
  21. cap each charge and the account total at 100% of billed charges
100% Profee Fees Schedule 50% Lab4 base · 20 adj
Humana Medicare
Profee · CVP_MIDWEST, NOVUS, RS_OHIO · 2023-01-01 → 2023-12-31
Humana Medicare
Profee · QUANTUM · 2023-01-01 → 2999-12-31
Humana Medicare
Profee · CAVANAUGH · 2023-01-01 → 2999-12-31
Base terms — first match wins
  1. flat $0 — when NoncoverageStatus Noncovered is present
  2. 100% of Medicare drug
  3. 50% of Medicare lab
  4. 100% of the Profee-Fees fee schedule
Adjustments — all apply, in order
  1. Medicare multiple-procedure reduction — base codes 2, 3; pays 100/50% — when Modifier 55 is absent; Modifier 82 is absent
  2. Medicare multiple-endoscopy reduction
  3. Medicare multiple-radiology reduction — base codes 4
  4. Medicare bilateral-surgery adjustment
  5. mid-level provider reduction (by NUCC taxonomy)
  6. modifier 22 present → 135% of the running amount
  7. modifier 52 present → 50% of the running amount
  8. custom SQL — Same global-surgery post-op allocation as hash c5fd5754fcf4a52d (Allowed/GlobalDays*PostOpRate), but hardened: falls back to returning {Allowed} unchanged when GLOB_DAYS or POST_OP is missing/non-numeric/zero instead of dividing by zero. — when Modifier 55 is present
  9. modifier 54 present → 80% of the running amount
  10. modifier 62 present → 62.5% of the running amount
  11. modifier 73 present → 50% of the running amount
  12. modifier 78 present → 70% of the running amount
  13. modifier 80 present → 16% of the running amount
  14. modifier 81 present → 16% of the running amount
  15. modifier 82 present → 16% of the running amount
  16. modifier AS present → 14% of the running amount
  17. modifier QY present → 50% of the running amount
  18. modifier QK present → 50% of the running amount
  19. modifier QX present → 50% of the running amount
  20. cap each charge and the account total at 100% of billed charges
100% Profee Fees Schedule 50% Lab WITH Seq4 base · 20 adj
Humana Medicare
Profee · EyePhysiciansPinellas · 2023-01-01 → 2999-12-31
Humana Medicare
Profee · GRENE_VISION · 2022-01-01 → 2999-12-31
Base terms — first match wins
  1. flat $0 — when NoncoverageStatus Noncovered is present
  2. 100% of Medicare drug
  3. 50% of Medicare lab
  4. 100% of the Profee-Fees fee schedule
Adjustments — all apply, in order
  1. Medicare multiple-procedure reduction — base codes 2, 3; pays 100/50% — when Modifier 55 is absent; Modifier 82 is absent
  2. Medicare multiple-endoscopy reduction
  3. Medicare multiple-radiology reduction — base codes 4
  4. Medicare bilateral-surgery adjustment
  5. mid-level provider reduction (by NUCC taxonomy)
  6. modifier 22 present → 135% of the running amount
  7. modifier 52 present → 50% of the running amount
  8. custom SQL — Same global-surgery post-op allocation as hash c5fd5754fcf4a52d (Allowed/GlobalDays*PostOpRate), but hardened: falls back to returning {Allowed} unchanged when GLOB_DAYS or POST_OP is missing/non-numeric/zero instead of dividing by zero. — when Modifier 55 is present
  9. modifier 54 present → 80% of the running amount
  10. modifier 62 present → 62.5% of the running amount
  11. modifier 73 present → 50% of the running amount
  12. modifier 78 present → 70% of the running amount
  13. modifier 80 present → 16% of the running amount
  14. modifier 81 present → 16% of the running amount
  15. modifier 82 present → 16% of the running amount
  16. modifier AS present → 14% of the running amount
  17. modifier QY present → 50% of the running amount
  18. modifier QK present → 50% of the running amount
  19. modifier QX present → 50% of the running amount
  20. cap each charge and the account total at 100% of billed charges
100% Profee Fees Schedule 90% Drug - UHC3 base · 22 adj
United Healthcare
Profee · CVP_MIDATLANTIC · 2023-01-01 → 2099-12-31
Base terms — first match wins
  1. flat $0 — when NoncoverageStatus Noncovered is present
  2. 90% of Medicare drug
  3. 100% of the Profee-Fees fee schedule
Adjustments — all apply, in order
  1. Medicare multiple-procedure reduction — base codes 2, 3; pays 100/50% — when Modifier 55 is absent; Modifier 82 is absent
  2. Medicare multiple-endoscopy reduction
  3. Medicare multiple-radiology reduction — base codes 4
  4. Medicare bilateral-surgery adjustment
  5. mid-level provider reduction (by NUCC taxonomy)
  6. modifier 22 present → 135% of the running amount
  7. modifier 53 present → 25% of the running amount
  8. modifier 52 present → 50% of the running amount
  9. custom SQL — Same global-surgery post-op allocation as hash c5fd5754fcf4a52d (Allowed/GlobalDays*PostOpRate), but hardened: falls back to returning {Allowed} unchanged when GLOB_DAYS or POST_OP is missing/non-numeric/zero instead of dividing by zero. — when Modifier 55 is present
  10. modifier 54 present → 80% of the running amount
  11. modifier 62 present → 62.5% of the running amount
  12. modifier 73 present → 50% of the running amount
  13. modifier 78 present → 70% of the running amount
  14. modifier 80 present → 16% of the running amount
  15. modifier 81 present → 16% of the running amount
  16. modifier 82 present → 16% of the running amount
  17. modifier AS present → 14% of the running amount
  18. modifier QY present → 50% of the running amount
  19. modifier QK present → 50% of the running amount
  20. modifier QX present → 50% of the running amount
  21. modifier QZ present → 85% of the running amount
  22. cap each charge and the account total at 100% of billed charges
100% Profee Fees Schedule with Carveouts4 base · 20 adj
Anthem Commercial Plans
Profee · KENYON_ASC_NEXTGEN, KENYON_NEXTGEN · 2023-01-01 → 2999-12-31
Anthem Commercial Plans, Anthem HMO, Anthem PPO
Profee · PADUCAH · 2024-11-01 → 2999-12-31
Base terms — first match wins
  1. flat $0 — when NoncoverageStatus Noncovered is present
  2. 100% of Medicare drug
  3. 100% of the Carveouts fee schedule
  4. 100% of the Profee-Fees fee schedule
Adjustments — all apply, in order
  1. Medicare multiple-procedure reduction — base codes 2, 3; pays 100/50% — when Modifier 55 is absent; Modifier 82 is absent
  2. Medicare multiple-endoscopy reduction
  3. Medicare multiple-radiology reduction — base codes 4
  4. Medicare bilateral-surgery adjustment
  5. mid-level provider reduction (by NUCC taxonomy)
  6. modifier 22 present → 135% of the running amount
  7. modifier 52 present → 50% of the running amount
  8. custom SQL — Same global-surgery post-op allocation as hash c5fd5754fcf4a52d (Allowed/GlobalDays*PostOpRate), but hardened: falls back to returning {Allowed} unchanged when GLOB_DAYS or POST_OP is missing/non-numeric/zero instead of dividing by zero. — when Modifier 55 is present
  9. modifier 54 present → 80% of the running amount
  10. modifier 62 present → 62.5% of the running amount
  11. modifier 73 present → 50% of the running amount
  12. modifier 78 present → 70% of the running amount
  13. modifier 80 present → 16% of the running amount
  14. modifier 81 present → 16% of the running amount
  15. modifier 82 present → 16% of the running amount
  16. modifier AS present → 14% of the running amount
  17. modifier QY present → 50% of the running amount
  18. modifier QK present → 50% of the running amount
  19. modifier QX present → 50% of the running amount
  20. cap each charge and the account total at 100% of billed charges
101% Medicare7 base · 21 adj
Aetna
Profee · LargoASC · 2025-05-01 → 2026-04-30
Base terms — first match wins
  1. flat $0 — when NoncoverageStatus Noncovered is present
  2. 101% of Medicare lab
  3. 100% of Medicare drug
  4. 101% of Medicare DME
  5. 101% of Medicare RVU — when PlaceOfService 2 is present
  6. 101% of Medicare RVU
  7. 0% of billed charges
Adjustments — all apply, in order
  1. Medicare multiple-procedure reduction — base codes 2, 3; pays 100/50/25% — when Modifier 55 is absent; Modifier 82 is absent
  2. Medicare multiple-ophthalmology reduction — base codes 7; pays 100/80%
  3. Medicare multiple-endoscopy reduction
  4. Medicare multiple-radiology reduction — base codes 4
  5. Medicare bilateral-surgery adjustment
  6. mid-level provider reduction (by NUCC taxonomy)
  7. modifier 22 present → 135% of the running amount
  8. modifier 52 present → 50% of the running amount
  9. custom SQL — Same global-surgery post-op allocation as hash c5fd5754fcf4a52d (Allowed/GlobalDays*PostOpRate), but hardened: falls back to returning {Allowed} unchanged when GLOB_DAYS or POST_OP is missing/non-numeric/zero instead of dividing by zero. — when Modifier 55 is present
  10. modifier 54 present → 80% of the running amount
  11. modifier 62 present → 62.5% of the running amount
  12. modifier 73 present → 50% of the running amount
  13. modifier 78 present → 70% of the running amount
  14. modifier 80 present → 16% of the running amount
  15. modifier 81 present → 16% of the running amount
  16. modifier 82 present → 16% of the running amount
  17. modifier AS present → 14% of the running amount
  18. modifier QY present → 50% of the running amount
  19. modifier QK present → 50% of the running amount
  20. modifier QX present → 50% of the running amount
  21. cap each charge and the account total at 100% of billed charges
101%-Medicare-ASC3 base · 22 adj
Aetna
Facility · LargoASC · 2025-05-01 → 2026-04-30
Base terms — first match wins
  1. flat $0 — when NoncoverageStatus Noncovered is present
  2. 101% of Medicare ASC
  3. flat $0
Adjustments — all apply, in order
  1. multiple-surgery reduction (contract rules) — pays 100/50/25%
  2. Medicare multiple-procedure reduction — base codes 2; pays 100/50/25%
  3. Medicare multiple-ophthalmology reduction — base codes 7; pays 100/80%
  4. Medicare multiple-endoscopy reduction
  5. Medicare multiple-radiology reduction — base codes 4
  6. Medicare bilateral-surgery adjustment
  7. mid-level provider reduction (by NUCC taxonomy)
  8. modifier 22 present → 135% of the running amount
  9. modifier 52 present → 50% of the running amount
  10. custom SQL — Same global-surgery post-op allocation as hash c5fd5754fcf4a52d (Allowed/GlobalDays*PostOpRate), but hardened: falls back to returning {Allowed} unchanged when GLOB_DAYS or POST_OP is missing/non-numeric/zero instead of dividing by zero. — when Modifier 55 is present
  11. modifier 54 present → 80% of the running amount
  12. modifier 62 present → 62.5% of the running amount
  13. modifier 73 present → 50% of the running amount
  14. modifier 78 present → 70% of the running amount
  15. modifier 80 present → 16% of the running amount
  16. modifier 81 present → 16% of the running amount
  17. modifier 82 present → 16% of the running amount
  18. modifier AS present → 14% of the running amount
  19. modifier QY present → 50% of the running amount
  20. modifier QK present → 50% of the running amount
  21. modifier QX present → 50% of the running amount
  22. cap each charge and the account total at 100% of billed charges
102% Medicare7 base · 20 adj
Cigna Medicare
Profee · CVP_MIDWEST, NOVUS, RS_OHIO · 2023-01-01 → 2999-12-31
VA Premier Medicare
Profee · CVP_MIDATLANTIC · 2023-01-01 → 2999-12-31
Base terms — first match wins
  1. flat $0 — when NoncoverageStatus Noncovered is present
  2. 102% of Medicare lab
  3. 100% of Medicare drug
  4. 102% of Medicare DME
  5. 102% of Medicare RVU — when PlaceOfService 2 is present
  6. 102% of Medicare RVU
  7. 0% of billed charges
Adjustments — all apply, in order
  1. Medicare multiple-procedure reduction — base codes 2, 3; pays 100/50% — when Modifier 55 is absent; Modifier 82 is absent
  2. Medicare multiple-endoscopy reduction
  3. Medicare multiple-radiology reduction — base codes 4
  4. Medicare bilateral-surgery adjustment
  5. mid-level provider reduction (by NUCC taxonomy)
  6. modifier 22 present → 135% of the running amount
  7. modifier 52 present → 50% of the running amount
  8. custom SQL — Same global-surgery post-op allocation as hash c5fd5754fcf4a52d (Allowed/GlobalDays*PostOpRate), but hardened: falls back to returning {Allowed} unchanged when GLOB_DAYS or POST_OP is missing/non-numeric/zero instead of dividing by zero. — when Modifier 55 is present
  9. modifier 54 present → 80% of the running amount
  10. modifier 62 present → 62.5% of the running amount
  11. modifier 73 present → 50% of the running amount
  12. modifier 78 present → 70% of the running amount
  13. modifier 80 present → 16% of the running amount
  14. modifier 81 present → 16% of the running amount
  15. modifier 82 present → 16% of the running amount
  16. modifier AS present → 14% of the running amount
  17. modifier QY present → 50% of the running amount
  18. modifier QK present → 50% of the running amount
  19. modifier QX present → 50% of the running amount
  20. cap each charge and the account total at 100% of billed charges
103%-Medicare-ASC3 base · 21 adj
Amerihealth
Facility · CVP_MIDWEST, NOVUS, RS_OHIO · 2025-05-01 → 2026-04-30
Base terms — first match wins
  1. flat $0 — when NoncoverageStatus Noncovered is present
  2. 103% of Medicare ASC
  3. flat $0
Adjustments — all apply, in order
  1. multiple-surgery reduction (contract rules) — pays 100/50%
  2. Medicare multiple-procedure reduction — base codes 2; pays 100/50%
  3. Medicare multiple-endoscopy reduction
  4. Medicare multiple-radiology reduction — base codes 4
  5. Medicare bilateral-surgery adjustment
  6. mid-level provider reduction (by NUCC taxonomy)
  7. modifier 22 present → 135% of the running amount
  8. modifier 52 present → 50% of the running amount
  9. custom SQL — Same global-surgery post-op allocation as hash c5fd5754fcf4a52d (Allowed/GlobalDays*PostOpRate), but hardened: falls back to returning {Allowed} unchanged when GLOB_DAYS or POST_OP is missing/non-numeric/zero instead of dividing by zero. — when Modifier 55 is present
  10. modifier 54 present → 80% of the running amount
  11. modifier 62 present → 62.5% of the running amount
  12. modifier 73 present → 50% of the running amount
  13. modifier 78 present → 70% of the running amount
  14. modifier 80 present → 16% of the running amount
  15. modifier 81 present → 16% of the running amount
  16. modifier 82 present → 16% of the running amount
  17. modifier AS present → 14% of the running amount
  18. modifier QY present → 50% of the running amount
  19. modifier QK present → 50% of the running amount
  20. modifier QX present → 50% of the running amount
  21. cap each charge and the account total at 100% of billed charges
104% Medicare7 base · 21 adj
Aetna
Profee · LargoASC · 2026-05-01 → 2999-12-31
Base terms — first match wins
  1. flat $0 — when NoncoverageStatus Noncovered is present
  2. 104% of Medicare lab
  3. 100% of Medicare drug
  4. 104% of Medicare DME
  5. 104% of Medicare RVU — when PlaceOfService 2 is present
  6. 104% of Medicare RVU
  7. 0% of billed charges
Adjustments — all apply, in order
  1. Medicare multiple-procedure reduction — base codes 2, 3; pays 100/50/25% — when Modifier 55 is absent; Modifier 82 is absent
  2. Medicare multiple-ophthalmology reduction — base codes 7; pays 100/80%
  3. Medicare multiple-endoscopy reduction
  4. Medicare multiple-radiology reduction — base codes 4
  5. Medicare bilateral-surgery adjustment
  6. mid-level provider reduction (by NUCC taxonomy)
  7. modifier 22 present → 135% of the running amount
  8. modifier 52 present → 50% of the running amount
  9. custom SQL — Same global-surgery post-op allocation as hash c5fd5754fcf4a52d (Allowed/GlobalDays*PostOpRate), but hardened: falls back to returning {Allowed} unchanged when GLOB_DAYS or POST_OP is missing/non-numeric/zero instead of dividing by zero. — when Modifier 55 is present
  10. modifier 54 present → 80% of the running amount
  11. modifier 62 present → 62.5% of the running amount
  12. modifier 73 present → 50% of the running amount
  13. modifier 78 present → 70% of the running amount
  14. modifier 80 present → 16% of the running amount
  15. modifier 81 present → 16% of the running amount
  16. modifier 82 present → 16% of the running amount
  17. modifier AS present → 14% of the running amount
  18. modifier QY present → 50% of the running amount
  19. modifier QK present → 50% of the running amount
  20. modifier QX present → 50% of the running amount
  21. cap each charge and the account total at 100% of billed charges
104%-Medicare-ASC3 base · 22 adj
Aetna
Facility · LargoASC · 2026-05-01 → 2999-12-31
Base terms — first match wins
  1. flat $0 — when NoncoverageStatus Noncovered is present
  2. 104% of Medicare ASC
  3. flat $0
Adjustments — all apply, in order
  1. multiple-surgery reduction (contract rules) — pays 100/50/25%
  2. Medicare multiple-procedure reduction — base codes 2; pays 100/50/25%
  3. Medicare multiple-ophthalmology reduction — base codes 7; pays 100/80%
  4. Medicare multiple-endoscopy reduction
  5. Medicare multiple-radiology reduction — base codes 4
  6. Medicare bilateral-surgery adjustment
  7. mid-level provider reduction (by NUCC taxonomy)
  8. modifier 22 present → 135% of the running amount
  9. modifier 52 present → 50% of the running amount
  10. custom SQL — Same global-surgery post-op allocation as hash c5fd5754fcf4a52d (Allowed/GlobalDays*PostOpRate), but hardened: falls back to returning {Allowed} unchanged when GLOB_DAYS or POST_OP is missing/non-numeric/zero instead of dividing by zero. — when Modifier 55 is present
  11. modifier 54 present → 80% of the running amount
  12. modifier 62 present → 62.5% of the running amount
  13. modifier 73 present → 50% of the running amount
  14. modifier 78 present → 70% of the running amount
  15. modifier 80 present → 16% of the running amount
  16. modifier 81 present → 16% of the running amount
  17. modifier 82 present → 16% of the running amount
  18. modifier AS present → 14% of the running amount
  19. modifier QY present → 50% of the running amount
  20. modifier QK present → 50% of the running amount
  21. modifier QX present → 50% of the running amount
  22. cap each charge and the account total at 100% of billed charges
105% Medicare7 base · 20 adj
Aetna Cofinity Medicare
Profee · ASSOCIATED_RETINAL · 2023-01-01 → 2999-12-31
Aetna Cofinity Medicare
Profee · BSV_EyeClinicMichigan · 2023-01-01 → 2999-12-31
Buckeye Medicare
Profee · CVP_MIDWEST, NOVUS, RS_OHIO · 2023-01-01 → 2999-12-31
SummaHealth PHO Medicare
Profee · CVP_MIDWEST, NOVUS, RS_OHIO · 2022-06-15 → 2999-12-31
The Health Plan Medicare
Profee · CVP_MIDWEST, NOVUS, RS_OHIO · 2023-01-01 → 2999-12-31
Valor
Profee · CVP_MIDWEST, NOVUS, RS_OHIO · 2023-01-01 → 2999-12-31
Base terms — first match wins
  1. flat $0 — when NoncoverageStatus Noncovered is present
  2. 105% of Medicare lab
  3. 100% of Medicare drug
  4. 105% of Medicare DME
  5. 105% of Medicare RVU — when PlaceOfService 2 is present
  6. 105% of Medicare RVU
  7. 0% of billed charges
Adjustments — all apply, in order
  1. Medicare multiple-procedure reduction — base codes 2, 3; pays 100/50% — when Modifier 55 is absent; Modifier 82 is absent
  2. Medicare multiple-endoscopy reduction
  3. Medicare multiple-radiology reduction — base codes 4
  4. Medicare bilateral-surgery adjustment
  5. mid-level provider reduction (by NUCC taxonomy)
  6. modifier 22 present → 135% of the running amount
  7. modifier 52 present → 50% of the running amount
  8. custom SQL — Same global-surgery post-op allocation as hash c5fd5754fcf4a52d (Allowed/GlobalDays*PostOpRate), but hardened: falls back to returning {Allowed} unchanged when GLOB_DAYS or POST_OP is missing/non-numeric/zero instead of dividing by zero. — when Modifier 55 is present
  9. modifier 54 present → 80% of the running amount
  10. modifier 62 present → 62.5% of the running amount
  11. modifier 73 present → 50% of the running amount
  12. modifier 78 present → 70% of the running amount
  13. modifier 80 present → 16% of the running amount
  14. modifier 81 present → 16% of the running amount
  15. modifier 82 present → 16% of the running amount
  16. modifier AS present → 14% of the running amount
  17. modifier QY present → 50% of the running amount
  18. modifier QK present → 50% of the running amount
  19. modifier QX present → 50% of the running amount
  20. cap each charge and the account total at 100% of billed charges
105% Medicare - No Sequestration7 base · 20 adj
Centene Ascension
Profee · ASSOCIATED_RETINAL · 2023-01-01 → 2999-12-31
Centene Ascension
Profee · BSV_EyeClinicMichigan · 2023-01-01 → 2999-12-31
Centene Ascension
Profee · BYRD_AND_WYAN · 2023-01-01 → 2999-12-31
Aetna Exchange
Profee · StPetersburgASC · 2023-01-01 → 2999-12-31
Essence
Profee · CVP_MIDWEST, NOVUS, RS_OHIO · 2023-01-01 → 2999-12-31
Molina Marketplace KY
Profee · CVP_MIDWEST, NOVUS, RS_OHIO · 2023-06-15 → 2999-12-31
SummaCare
Profee · CVP_MIDWEST, NOVUS, RS_OHIO · 2022-06-15 → 2999-12-31
Base terms — first match wins
  1. flat $0 — when NoncoverageStatus Noncovered is present
  2. 105% of Medicare lab
  3. 100% of Medicare drug
  4. 105% of Medicare DME
  5. 105% of Medicare RVU — when PlaceOfService 2 is present
  6. 105% of Medicare RVU
  7. 0% of billed charges
Adjustments — all apply, in order
  1. Medicare multiple-procedure reduction — base codes 2, 3; pays 100/50% — when Modifier 55 is absent; Modifier 82 is absent
  2. Medicare multiple-endoscopy reduction
  3. Medicare multiple-radiology reduction — base codes 4
  4. Medicare bilateral-surgery adjustment
  5. mid-level provider reduction (by NUCC taxonomy)
  6. modifier 22 present → 135% of the running amount
  7. modifier 52 present → 50% of the running amount
  8. custom SQL — Same global-surgery post-op allocation as hash c5fd5754fcf4a52d (Allowed/GlobalDays*PostOpRate), but hardened: falls back to returning {Allowed} unchanged when GLOB_DAYS or POST_OP is missing/non-numeric/zero instead of dividing by zero. — when Modifier 55 is present
  9. modifier 54 present → 80% of the running amount
  10. modifier 62 present → 62.5% of the running amount
  11. modifier 73 present → 50% of the running amount
  12. modifier 78 present → 70% of the running amount
  13. modifier 80 present → 16% of the running amount
  14. modifier 81 present → 16% of the running amount
  15. modifier 82 present → 16% of the running amount
  16. modifier AS present → 14% of the running amount
  17. modifier QY present → 50% of the running amount
  18. modifier QK present → 50% of the running amount
  19. modifier QX present → 50% of the running amount
  20. cap each charge and the account total at 100% of billed charges
105%-Medicare-ASC3 base · 21 adj
Aetna Cofinity Medicare
Facility · ASSOCIATED_RETINAL · 2023-01-01 → 2999-12-31
Centene Ascension
Facility · ASSOCIATED_RETINAL · 2023-01-01 → 2999-12-31
Aetna Cofinity Medicare
Facility · BSV_EyeClinicMichigan · 2023-01-01 → 2999-12-31
Centene Ascension
Facility · BSV_EyeClinicMichigan · 2023-01-01 → 2999-12-31
Centene Ascension
Facility · BSV_TukelEye · 2023-01-01 → 2999-12-31
Centene Ascension
Facility · BYRD_AND_WYAN · 2023-01-01 → 2999-12-31
Aetna Exchange
Facility · StPetersburgASC · 2023-01-01 → 2999-12-31
Base terms — first match wins
  1. flat $0 — when NoncoverageStatus Noncovered is present
  2. 105% of Medicare ASC
  3. flat $0
Adjustments — all apply, in order
  1. multiple-surgery reduction (contract rules) — pays 100/50%
  2. Medicare multiple-procedure reduction — base codes 2; pays 100/50%
  3. Medicare multiple-endoscopy reduction
  4. Medicare multiple-radiology reduction — base codes 4
  5. Medicare bilateral-surgery adjustment
  6. mid-level provider reduction (by NUCC taxonomy)
  7. modifier 22 present → 135% of the running amount
  8. modifier 52 present → 50% of the running amount
  9. custom SQL — Same global-surgery post-op allocation as hash c5fd5754fcf4a52d (Allowed/GlobalDays*PostOpRate), but hardened: falls back to returning {Allowed} unchanged when GLOB_DAYS or POST_OP is missing/non-numeric/zero instead of dividing by zero. — when Modifier 55 is present
  10. modifier 54 present → 80% of the running amount
  11. modifier 62 present → 62.5% of the running amount
  12. modifier 73 present → 50% of the running amount
  13. modifier 78 present → 70% of the running amount
  14. modifier 80 present → 16% of the running amount
  15. modifier 81 present → 16% of the running amount
  16. modifier 82 present → 16% of the running amount
  17. modifier AS present → 14% of the running amount
  18. modifier QY present → 50% of the running amount
  19. modifier QK present → 50% of the running amount
  20. modifier QX present → 50% of the running amount
  21. cap each charge and the account total at 100% of billed charges
109% Medicare7 base · 20 adj
Zing Medicare
Profee · ASSOCIATED_RETINAL · 2023-01-01 → 2999-12-31
Base terms — first match wins
  1. flat $0 — when NoncoverageStatus Noncovered is present
  2. 100% of Medicare lab
  3. 100% of Medicare drug
  4. 100% of Medicare DME
  5. 109% of Medicare RVU — when PlaceOfService 2 is present
  6. 109% of Medicare RVU
  7. 0% of billed charges
Adjustments — all apply, in order
  1. Medicare multiple-procedure reduction — base codes 2, 3; pays 100/50% — when Modifier 55 is absent; Modifier 82 is absent
  2. Medicare multiple-endoscopy reduction
  3. Medicare multiple-radiology reduction — base codes 4
  4. Medicare bilateral-surgery adjustment
  5. mid-level provider reduction (by NUCC taxonomy)
  6. modifier 22 present → 135% of the running amount
  7. modifier 52 present → 50% of the running amount
  8. custom SQL — Same global-surgery post-op allocation as hash c5fd5754fcf4a52d (Allowed/GlobalDays*PostOpRate), but hardened: falls back to returning {Allowed} unchanged when GLOB_DAYS or POST_OP is missing/non-numeric/zero instead of dividing by zero. — when Modifier 55 is present
  9. modifier 54 present → 80% of the running amount
  10. modifier 62 present → 62.5% of the running amount
  11. modifier 73 present → 50% of the running amount
  12. modifier 78 present → 70% of the running amount
  13. modifier 80 present → 16% of the running amount
  14. modifier 81 present → 16% of the running amount
  15. modifier 82 present → 16% of the running amount
  16. modifier AS present → 14% of the running amount
  17. modifier QY present → 50% of the running amount
  18. modifier QK present → 50% of the running amount
  19. modifier QX present → 50% of the running amount
  20. cap each charge and the account total at 100% of billed charges
109%-Medicare-ASC3 base · 21 adj
Zing Medicare
Facility · ASSOCIATED_RETINAL · 2023-01-01 → 2999-12-31
Base terms — first match wins
  1. flat $0 — when NoncoverageStatus Noncovered is present
  2. 109% of Medicare ASC
  3. flat $0
Adjustments — all apply, in order
  1. multiple-surgery reduction (contract rules) — pays 100/50%
  2. Medicare multiple-procedure reduction — base codes 2; pays 100/50%
  3. Medicare multiple-endoscopy reduction
  4. Medicare multiple-radiology reduction — base codes 4
  5. Medicare bilateral-surgery adjustment
  6. mid-level provider reduction (by NUCC taxonomy)
  7. modifier 22 present → 135% of the running amount
  8. modifier 52 present → 50% of the running amount
  9. custom SQL — Same global-surgery post-op allocation as hash c5fd5754fcf4a52d (Allowed/GlobalDays*PostOpRate), but hardened: falls back to returning {Allowed} unchanged when GLOB_DAYS or POST_OP is missing/non-numeric/zero instead of dividing by zero. — when Modifier 55 is present
  10. modifier 54 present → 80% of the running amount
  11. modifier 62 present → 62.5% of the running amount
  12. modifier 73 present → 50% of the running amount
  13. modifier 78 present → 70% of the running amount
  14. modifier 80 present → 16% of the running amount
  15. modifier 81 present → 16% of the running amount
  16. modifier 82 present → 16% of the running amount
  17. modifier AS present → 14% of the running amount
  18. modifier QY present → 50% of the running amount
  19. modifier QK present → 50% of the running amount
  20. modifier QX present → 50% of the running amount
  21. cap each charge and the account total at 100% of billed charges
110% Medicare7 base · 20 adj
Clevland Clinic Employee CIN
Profee · CVP_MIDWEST, NOVUS, RS_OHIO · 2023-01-01 → 2999-12-31
Meridian Medicare
Profee · CVP_MIDWEST, NOVUS, RS_OHIO · 2023-01-01 → 2999-12-31
Essence
Profee · OPHC_NEXTGEN · 2023-01-01 → 2999-12-31
Humana
Profee · OPHC_NEXTGEN · 2023-01-01 → 2999-12-31
Base terms — first match wins
  1. flat $0 — when NoncoverageStatus Noncovered is present
  2. 110% of Medicare lab
  3. 100% of Medicare drug
  4. 110% of Medicare DME
  5. 110% of Medicare RVU — when PlaceOfService 2 is present
  6. 110% of Medicare RVU
  7. 0% of billed charges
Adjustments — all apply, in order
  1. Medicare multiple-procedure reduction — base codes 2, 3; pays 100/50% — when Modifier 55 is absent; Modifier 82 is absent
  2. Medicare multiple-endoscopy reduction
  3. Medicare multiple-radiology reduction — base codes 4
  4. Medicare bilateral-surgery adjustment
  5. mid-level provider reduction (by NUCC taxonomy)
  6. modifier 22 present → 135% of the running amount
  7. modifier 52 present → 50% of the running amount
  8. custom SQL — Same global-surgery post-op allocation as hash c5fd5754fcf4a52d (Allowed/GlobalDays*PostOpRate), but hardened: falls back to returning {Allowed} unchanged when GLOB_DAYS or POST_OP is missing/non-numeric/zero instead of dividing by zero. — when Modifier 55 is present
  9. modifier 54 present → 80% of the running amount
  10. modifier 62 present → 62.5% of the running amount
  11. modifier 73 present → 50% of the running amount
  12. modifier 78 present → 70% of the running amount
  13. modifier 80 present → 16% of the running amount
  14. modifier 81 present → 16% of the running amount
  15. modifier 82 present → 16% of the running amount
  16. modifier AS present → 14% of the running amount
  17. modifier QY present → 50% of the running amount
  18. modifier QK present → 50% of the running amount
  19. modifier QX present → 50% of the running amount
  20. cap each charge and the account total at 100% of billed charges
120% Medicare7 base · 20 adj
PNOA
Profee · ASSOCIATED_RETINAL · 2023-01-01 → 2999-12-31
Evolutions, Evolutions Tier 1
Profee · EIWF · 2023-01-01 → 2999-12-31
Base terms — first match wins
  1. flat $0 — when NoncoverageStatus Noncovered is present
  2. 120% of Medicare lab
  3. 100% of Medicare drug
  4. 120% of Medicare DME
  5. 120% of Medicare RVU — when PlaceOfService 2 is present
  6. 120% of Medicare RVU
  7. 0% of billed charges
Adjustments — all apply, in order
  1. Medicare multiple-procedure reduction — base codes 2, 3; pays 100/50% — when Modifier 55 is absent; Modifier 82 is absent
  2. Medicare multiple-endoscopy reduction
  3. Medicare multiple-radiology reduction — base codes 4
  4. Medicare bilateral-surgery adjustment
  5. mid-level provider reduction (by NUCC taxonomy)
  6. modifier 22 present → 135% of the running amount
  7. modifier 52 present → 50% of the running amount
  8. custom SQL — Same global-surgery post-op allocation as hash c5fd5754fcf4a52d (Allowed/GlobalDays*PostOpRate), but hardened: falls back to returning {Allowed} unchanged when GLOB_DAYS or POST_OP is missing/non-numeric/zero instead of dividing by zero. — when Modifier 55 is present
  9. modifier 54 present → 80% of the running amount
  10. modifier 62 present → 62.5% of the running amount
  11. modifier 73 present → 50% of the running amount
  12. modifier 78 present → 70% of the running amount
  13. modifier 80 present → 16% of the running amount
  14. modifier 81 present → 16% of the running amount
  15. modifier 82 present → 16% of the running amount
  16. modifier AS present → 14% of the running amount
  17. modifier QY present → 50% of the running amount
  18. modifier QK present → 50% of the running amount
  19. modifier QX present → 50% of the running amount
  20. cap each charge and the account total at 100% of billed charges
120%-Medicare-ASC3 base · 21 adj
PNOA
Facility · ASSOCIATED_RETINAL · 2023-01-01 → 2999-12-31
Base terms — first match wins
  1. flat $0 — when NoncoverageStatus Noncovered is present
  2. 120% of Medicare ASC
  3. flat $0
Adjustments — all apply, in order
  1. multiple-surgery reduction (contract rules) — pays 100/50%
  2. Medicare multiple-procedure reduction — base codes 2; pays 100/50%
  3. Medicare multiple-endoscopy reduction
  4. Medicare multiple-radiology reduction — base codes 4
  5. Medicare bilateral-surgery adjustment
  6. mid-level provider reduction (by NUCC taxonomy)
  7. modifier 22 present → 135% of the running amount
  8. modifier 52 present → 50% of the running amount
  9. custom SQL — Same global-surgery post-op allocation as hash c5fd5754fcf4a52d (Allowed/GlobalDays*PostOpRate), but hardened: falls back to returning {Allowed} unchanged when GLOB_DAYS or POST_OP is missing/non-numeric/zero instead of dividing by zero. — when Modifier 55 is present
  10. modifier 54 present → 80% of the running amount
  11. modifier 62 present → 62.5% of the running amount
  12. modifier 73 present → 50% of the running amount
  13. modifier 78 present → 70% of the running amount
  14. modifier 80 present → 16% of the running amount
  15. modifier 81 present → 16% of the running amount
  16. modifier 82 present → 16% of the running amount
  17. modifier AS present → 14% of the running amount
  18. modifier QY present → 50% of the running amount
  19. modifier QK present → 50% of the running amount
  20. modifier QX present → 50% of the running amount
  21. cap each charge and the account total at 100% of billed charges
125% Medicare7 base · 20 adj
Piedmont Community Health Commercial
Profee · CVP_MIDATLANTIC · 2023-01-01 → 2999-12-31
Wexford
Profee · QUANTUM · 2023-01-01 → 2999-12-31
Base terms — first match wins
  1. flat $0 — when NoncoverageStatus Noncovered is present
  2. 125% of Medicare lab
  3. 100% of Medicare drug
  4. 125% of Medicare DME
  5. 125% of Medicare RVU — when PlaceOfService 2 is present
  6. 125% of Medicare RVU
  7. 0% of billed charges
Adjustments — all apply, in order
  1. Medicare multiple-procedure reduction — base codes 2, 3; pays 100/50% — when Modifier 55 is absent; Modifier 82 is absent
  2. Medicare multiple-endoscopy reduction
  3. Medicare multiple-radiology reduction — base codes 4
  4. Medicare bilateral-surgery adjustment
  5. mid-level provider reduction (by NUCC taxonomy)
  6. modifier 22 present → 135% of the running amount
  7. modifier 52 present → 50% of the running amount
  8. custom SQL — Same global-surgery post-op allocation as hash c5fd5754fcf4a52d (Allowed/GlobalDays*PostOpRate), but hardened: falls back to returning {Allowed} unchanged when GLOB_DAYS or POST_OP is missing/non-numeric/zero instead of dividing by zero. — when Modifier 55 is present
  9. modifier 54 present → 80% of the running amount
  10. modifier 62 present → 62.5% of the running amount
  11. modifier 73 present → 50% of the running amount
  12. modifier 78 present → 70% of the running amount
  13. modifier 80 present → 16% of the running amount
  14. modifier 81 present → 16% of the running amount
  15. modifier 82 present → 16% of the running amount
  16. modifier AS present → 14% of the running amount
  17. modifier QY present → 50% of the running amount
  18. modifier QK present → 50% of the running amount
  19. modifier QX present → 50% of the running amount
  20. cap each charge and the account total at 100% of billed charges
125%-Medicare-ASC3 base · 21 adj
Cigna
Facility · DEER_CREEK · 2019-06-15 → 2999-12-31
Base terms — first match wins
  1. flat $0 — when NoncoverageStatus Noncovered is present
  2. 125% of Medicare ASC
  3. flat $0
Adjustments — all apply, in order
  1. multiple-surgery reduction (contract rules) — pays 100/50%
  2. Medicare multiple-procedure reduction — base codes 2; pays 100/50%
  3. Medicare multiple-endoscopy reduction
  4. Medicare multiple-radiology reduction — base codes 4
  5. Medicare bilateral-surgery adjustment
  6. mid-level provider reduction (by NUCC taxonomy)
  7. modifier 22 present → 135% of the running amount
  8. modifier 52 present → 50% of the running amount
  9. custom SQL — Same global-surgery post-op allocation as hash c5fd5754fcf4a52d (Allowed/GlobalDays*PostOpRate), but hardened: falls back to returning {Allowed} unchanged when GLOB_DAYS or POST_OP is missing/non-numeric/zero instead of dividing by zero. — when Modifier 55 is present
  10. modifier 54 present → 80% of the running amount
  11. modifier 62 present → 62.5% of the running amount
  12. modifier 73 present → 50% of the running amount
  13. modifier 78 present → 70% of the running amount
  14. modifier 80 present → 16% of the running amount
  15. modifier 81 present → 16% of the running amount
  16. modifier 82 present → 16% of the running amount
  17. modifier AS present → 14% of the running amount
  18. modifier QY present → 50% of the running amount
  19. modifier QK present → 50% of the running amount
  20. modifier QX present → 50% of the running amount
  21. cap each charge and the account total at 100% of billed charges
130% Medicare7 base · 20 adj
Longevity Medicare
Profee · ASSOCIATED_RETINAL · 2023-01-01 → 2999-12-31
Longevity Medicare
Profee · BSV_EyeClinicMichigan · 2023-01-01 → 2999-12-31
Longevity Medicare
Profee · BSV_TukelEye · 2023-01-01 → 2999-12-31
Longevity Medicare
Profee · BYRD_AND_WYAN · 2023-01-01 → 2999-12-31
Base terms — first match wins
  1. flat $0 — when NoncoverageStatus Noncovered is present
  2. 130% of Medicare lab
  3. 100% of Medicare drug
  4. 130% of Medicare DME
  5. 130% of Medicare RVU — when PlaceOfService 2 is present
  6. 130% of Medicare RVU
  7. 0% of billed charges
Adjustments — all apply, in order
  1. Medicare multiple-procedure reduction — base codes 2, 3; pays 100/50% — when Modifier 55 is absent; Modifier 82 is absent
  2. Medicare multiple-endoscopy reduction
  3. Medicare multiple-radiology reduction — base codes 4
  4. Medicare bilateral-surgery adjustment
  5. mid-level provider reduction (by NUCC taxonomy)
  6. modifier 22 present → 135% of the running amount
  7. modifier 52 present → 50% of the running amount
  8. custom SQL — Same global-surgery post-op allocation as hash c5fd5754fcf4a52d (Allowed/GlobalDays*PostOpRate), but hardened: falls back to returning {Allowed} unchanged when GLOB_DAYS or POST_OP is missing/non-numeric/zero instead of dividing by zero. — when Modifier 55 is present
  9. modifier 54 present → 80% of the running amount
  10. modifier 62 present → 62.5% of the running amount
  11. modifier 73 present → 50% of the running amount
  12. modifier 78 present → 70% of the running amount
  13. modifier 80 present → 16% of the running amount
  14. modifier 81 present → 16% of the running amount
  15. modifier 82 present → 16% of the running amount
  16. modifier AS present → 14% of the running amount
  17. modifier QY present → 50% of the running amount
  18. modifier QK present → 50% of the running amount
  19. modifier QX present → 50% of the running amount
  20. cap each charge and the account total at 100% of billed charges
130% Medicare - No Sequestration7 base · 20 adj
HAP Commercial
Profee · ASSOCIATED_RETINAL · 2023-01-01 → 2999-12-31
HAP Commercial, HAP HMO, HAP PPO
Profee · HURON_OPH · 2023-01-01 → 2999-12-31
HAP PPO
Profee · BSV · 2023-01-01 → 2999-12-31
Humana
Profee · MCPEAK · 2024-05-01 → 2999-12-31
Humana
Profee · KENYON_ASC_NEXTGEN, KENYON_NEXTGEN · 2024-01-01 → 2999-12-31
Wellpath
Profee · ASC, Clinic, Home, Hospital, PA · 2024-01-01 → 2999-12-31
Base terms — first match wins
  1. flat $0 — when NoncoverageStatus Noncovered is present
  2. 130% of Medicare lab
  3. 100% of Medicare drug
  4. 130% of Medicare DME
  5. 130% of Medicare RVU — when PlaceOfService 2 is present
  6. 130% of Medicare RVU
  7. 0% of billed charges
Adjustments — all apply, in order
  1. Medicare multiple-procedure reduction — base codes 2, 3; pays 100/50% — when Modifier 55 is absent; Modifier 82 is absent
  2. Medicare multiple-endoscopy reduction
  3. Medicare multiple-radiology reduction — base codes 4
  4. Medicare bilateral-surgery adjustment
  5. mid-level provider reduction (by NUCC taxonomy)
  6. modifier 22 present → 135% of the running amount
  7. modifier 52 present → 50% of the running amount
  8. custom SQL — Same global-surgery post-op allocation as hash c5fd5754fcf4a52d (Allowed/GlobalDays*PostOpRate), but hardened: falls back to returning {Allowed} unchanged when GLOB_DAYS or POST_OP is missing/non-numeric/zero instead of dividing by zero. — when Modifier 55 is present
  9. modifier 54 present → 80% of the running amount
  10. modifier 62 present → 62.5% of the running amount
  11. modifier 73 present → 50% of the running amount
  12. modifier 78 present → 70% of the running amount
  13. modifier 80 present → 16% of the running amount
  14. modifier 81 present → 16% of the running amount
  15. modifier 82 present → 16% of the running amount
  16. modifier AS present → 14% of the running amount
  17. modifier QY present → 50% of the running amount
  18. modifier QK present → 50% of the running amount
  19. modifier QX present → 50% of the running amount
  20. cap each charge and the account total at 100% of billed charges
130% Medicare 100% Drug7 base · 20 adj
Buckeye Ambetter
Profee · CVP_MIDWEST, NOVUS, RS_OHIO · 2023-01-01 → 2999-12-31
Caresource
Profee · CVP_MIDWEST, NOVUS, RS_OHIO · 2023-01-01 → 2999-12-31
Humana
Profee · PADUCAH · 2024-05-01 → 2999-12-31
Base terms — first match wins
  1. flat $0 — when NoncoverageStatus Noncovered is present
  2. 130% of Medicare lab
  3. 100% of Medicare drug
  4. 130% of Medicare DME
  5. 130% of Medicare RVU — when PlaceOfService 2 is present
  6. 130% of Medicare RVU
  7. 0% of billed charges
Adjustments — all apply, in order
  1. Medicare multiple-procedure reduction — base codes 2, 3; pays 100/50% — when Modifier 55 is absent; Modifier 82 is absent
  2. Medicare multiple-endoscopy reduction
  3. Medicare multiple-radiology reduction — base codes 4
  4. Medicare bilateral-surgery adjustment
  5. mid-level provider reduction (by NUCC taxonomy)
  6. modifier 22 present → 135% of the running amount
  7. modifier 52 present → 50% of the running amount
  8. custom SQL — Same global-surgery post-op allocation as hash c5fd5754fcf4a52d (Allowed/GlobalDays*PostOpRate), but hardened: falls back to returning {Allowed} unchanged when GLOB_DAYS or POST_OP is missing/non-numeric/zero instead of dividing by zero. — when Modifier 55 is present
  9. modifier 54 present → 80% of the running amount
  10. modifier 62 present → 62.5% of the running amount
  11. modifier 73 present → 50% of the running amount
  12. modifier 78 present → 70% of the running amount
  13. modifier 80 present → 16% of the running amount
  14. modifier 81 present → 16% of the running amount
  15. modifier 82 present → 16% of the running amount
  16. modifier AS present → 14% of the running amount
  17. modifier QY present → 50% of the running amount
  18. modifier QK present → 50% of the running amount
  19. modifier QX present → 50% of the running amount
  20. cap each charge and the account total at 100% of billed charges
130%-Medicare-ASC3 base · 21 adj
HAP Commercial
Facility · ASSOCIATED_RETINAL · 2023-01-01 → 2999-12-31
Longevity Medicare
Facility · ASSOCIATED_RETINAL · 2023-01-01 → 2999-12-31
HAP Commercial, HAP HMO, HAP PPO
Facility · HURON_OPH · 2023-01-01 → 2999-12-31
Longevity Medicare
Facility · BSV_EyeClinicMichigan · 2023-01-01 → 2999-12-31
Longevity Medicare
Facility · BSV_TukelEye · 2023-01-01 → 2999-12-31
Longevity Medicare
Facility · BYRD_AND_WYAN · 2023-01-01 → 2999-12-31
HAP PPO
Facility · BSV · 2023-01-01 → 2999-12-31
Humana
Facility · MCPEAK · 2023-01-01 → 2999-12-31
Humana
Facility · KENYON_ASC_NEXTGEN · 2024-08-01 → 2999-12-31
Base terms — first match wins
  1. flat $0 — when NoncoverageStatus Noncovered is present
  2. 130% of Medicare ASC
  3. flat $0
Adjustments — all apply, in order
  1. multiple-surgery reduction (contract rules) — pays 100/50%
  2. Medicare multiple-procedure reduction — base codes 2; pays 100/50%
  3. Medicare multiple-endoscopy reduction
  4. Medicare multiple-radiology reduction — base codes 4
  5. Medicare bilateral-surgery adjustment
  6. mid-level provider reduction (by NUCC taxonomy)
  7. modifier 22 present → 135% of the running amount
  8. modifier 52 present → 50% of the running amount
  9. custom SQL — Same global-surgery post-op allocation as hash c5fd5754fcf4a52d (Allowed/GlobalDays*PostOpRate), but hardened: falls back to returning {Allowed} unchanged when GLOB_DAYS or POST_OP is missing/non-numeric/zero instead of dividing by zero. — when Modifier 55 is present
  10. modifier 54 present → 80% of the running amount
  11. modifier 62 present → 62.5% of the running amount
  12. modifier 73 present → 50% of the running amount
  13. modifier 78 present → 70% of the running amount
  14. modifier 80 present → 16% of the running amount
  15. modifier 81 present → 16% of the running amount
  16. modifier 82 present → 16% of the running amount
  17. modifier AS present → 14% of the running amount
  18. modifier QY present → 50% of the running amount
  19. modifier QK present → 50% of the running amount
  20. modifier QX present → 50% of the running amount
  21. cap each charge and the account total at 100% of billed charges
135%-Medicare-ASC3 base · 21 adj
Cigna
Facility · CATARACT_IOK · 2023-01-01 → 2999-12-31
Base terms — first match wins
  1. flat $0 — when NoncoverageStatus Noncovered is present
  2. 135% of Medicare ASC
  3. flat $0
Adjustments — all apply, in order
  1. multiple-surgery reduction (contract rules) — pays 100/50%
  2. Medicare multiple-procedure reduction — base codes 2; pays 100/50%
  3. Medicare multiple-endoscopy reduction
  4. Medicare multiple-radiology reduction — base codes 4
  5. Medicare bilateral-surgery adjustment
  6. mid-level provider reduction (by NUCC taxonomy)
  7. modifier 22 present → 135% of the running amount
  8. modifier 52 present → 50% of the running amount
  9. custom SQL — Same global-surgery post-op allocation as hash c5fd5754fcf4a52d (Allowed/GlobalDays*PostOpRate), but hardened: falls back to returning {Allowed} unchanged when GLOB_DAYS or POST_OP is missing/non-numeric/zero instead of dividing by zero. — when Modifier 55 is present
  10. modifier 54 present → 80% of the running amount
  11. modifier 62 present → 62.5% of the running amount
  12. modifier 73 present → 50% of the running amount
  13. modifier 78 present → 70% of the running amount
  14. modifier 80 present → 16% of the running amount
  15. modifier 81 present → 16% of the running amount
  16. modifier 82 present → 16% of the running amount
  17. modifier AS present → 14% of the running amount
  18. modifier QY present → 50% of the running amount
  19. modifier QK present → 50% of the running amount
  20. modifier QX present → 50% of the running amount
  21. cap each charge and the account total at 100% of billed charges
140% Medicare7 base · 20 adj
Poppins Health
Profee · CVP_MIDWEST, NOVUS, RS_OHIO · 2023-02-15 → 2999-12-31
Evolutions
Profee · LargoASC · 2023-01-01 → 2999-12-31
Base terms — first match wins
  1. flat $0 — when NoncoverageStatus Noncovered is present
  2. 140% of Medicare lab
  3. 100% of Medicare drug
  4. 140% of Medicare DME
  5. 140% of Medicare RVU — when PlaceOfService 2 is present
  6. 140% of Medicare RVU
  7. 0% of billed charges
Adjustments — all apply, in order
  1. Medicare multiple-procedure reduction — base codes 2, 3; pays 100/50% — when Modifier 55 is absent; Modifier 82 is absent
  2. Medicare multiple-endoscopy reduction
  3. Medicare multiple-radiology reduction — base codes 4
  4. Medicare bilateral-surgery adjustment
  5. mid-level provider reduction (by NUCC taxonomy)
  6. modifier 22 present → 135% of the running amount
  7. modifier 52 present → 50% of the running amount
  8. custom SQL — Same global-surgery post-op allocation as hash c5fd5754fcf4a52d (Allowed/GlobalDays*PostOpRate), but hardened: falls back to returning {Allowed} unchanged when GLOB_DAYS or POST_OP is missing/non-numeric/zero instead of dividing by zero. — when Modifier 55 is present
  9. modifier 54 present → 80% of the running amount
  10. modifier 62 present → 62.5% of the running amount
  11. modifier 73 present → 50% of the running amount
  12. modifier 78 present → 70% of the running amount
  13. modifier 80 present → 16% of the running amount
  14. modifier 81 present → 16% of the running amount
  15. modifier 82 present → 16% of the running amount
  16. modifier AS present → 14% of the running amount
  17. modifier QY present → 50% of the running amount
  18. modifier QK present → 50% of the running amount
  19. modifier QX present → 50% of the running amount
  20. cap each charge and the account total at 100% of billed charges
140%-Medicare-ASC3 base · 21 adj
Contigo
Facility · CATARACT_IOK · 2023-01-01 → 2999-12-31
Contigo
Facility · PRECISION_VISION · 2023-01-01 → 2999-12-31
Base terms — first match wins
  1. flat $0 — when NoncoverageStatus Noncovered is present
  2. 140% of Medicare ASC
  3. flat $0
Adjustments — all apply, in order
  1. multiple-surgery reduction (contract rules) — pays 100/50%
  2. Medicare multiple-procedure reduction — base codes 2; pays 100/50%
  3. Medicare multiple-endoscopy reduction
  4. Medicare multiple-radiology reduction — base codes 4
  5. Medicare bilateral-surgery adjustment
  6. mid-level provider reduction (by NUCC taxonomy)
  7. modifier 22 present → 135% of the running amount
  8. modifier 52 present → 50% of the running amount
  9. custom SQL — Same global-surgery post-op allocation as hash c5fd5754fcf4a52d (Allowed/GlobalDays*PostOpRate), but hardened: falls back to returning {Allowed} unchanged when GLOB_DAYS or POST_OP is missing/non-numeric/zero instead of dividing by zero. — when Modifier 55 is present
  10. modifier 54 present → 80% of the running amount
  11. modifier 62 present → 62.5% of the running amount
  12. modifier 73 present → 50% of the running amount
  13. modifier 78 present → 70% of the running amount
  14. modifier 80 present → 16% of the running amount
  15. modifier 81 present → 16% of the running amount
  16. modifier 82 present → 16% of the running amount
  17. modifier AS present → 14% of the running amount
  18. modifier QY present → 50% of the running amount
  19. modifier QK present → 50% of the running amount
  20. modifier QX present → 50% of the running amount
  21. cap each charge and the account total at 100% of billed charges
150% Medicare7 base · 20 adj
SummaHealth PHO Commercial
Profee · CVP_MIDWEST, NOVUS, RS_OHIO · 2023-01-01 → 2999-12-31
Base terms — first match wins
  1. flat $0 — when NoncoverageStatus Noncovered is present
  2. 150% of Medicare lab
  3. 100% of Medicare drug
  4. 150% of Medicare DME
  5. 150% of Medicare RVU — when PlaceOfService 2 is present
  6. 150% of Medicare RVU
  7. 0% of billed charges
Adjustments — all apply, in order
  1. Medicare multiple-procedure reduction — base codes 2, 3; pays 100/50% — when Modifier 55 is absent; Modifier 82 is absent
  2. Medicare multiple-endoscopy reduction
  3. Medicare multiple-radiology reduction — base codes 4
  4. Medicare bilateral-surgery adjustment
  5. mid-level provider reduction (by NUCC taxonomy)
  6. modifier 22 present → 135% of the running amount
  7. modifier 52 present → 50% of the running amount
  8. custom SQL — Same global-surgery post-op allocation as hash c5fd5754fcf4a52d (Allowed/GlobalDays*PostOpRate), but hardened: falls back to returning {Allowed} unchanged when GLOB_DAYS or POST_OP is missing/non-numeric/zero instead of dividing by zero. — when Modifier 55 is present
  9. modifier 54 present → 80% of the running amount
  10. modifier 62 present → 62.5% of the running amount
  11. modifier 73 present → 50% of the running amount
  12. modifier 78 present → 70% of the running amount
  13. modifier 80 present → 16% of the running amount
  14. modifier 81 present → 16% of the running amount
  15. modifier 82 present → 16% of the running amount
  16. modifier AS present → 14% of the running amount
  17. modifier QY present → 50% of the running amount
  18. modifier QK present → 50% of the running amount
  19. modifier QX present → 50% of the running amount
  20. cap each charge and the account total at 100% of billed charges
150% Medicare Rate - No Sequestration6 base · 20 adj
The Health Plan
Profee · CVP_MIDWEST, NOVUS, RS_OHIO · 2023-01-01 → 2999-12-31
Base terms — first match wins
  1. flat $0 — when NoncoverageStatus Noncovered is present
  2. 150% of Medicare lab
  3. 100% of Medicare drug
  4. 150% of Medicare DME
  5. 150% of Medicare RVU
  6. 0% of billed charges
Adjustments — all apply, in order
  1. Medicare multiple-procedure reduction — base codes 2, 3; pays 100/50% — when Modifier 55 is absent; Modifier 82 is absent
  2. Medicare multiple-endoscopy reduction
  3. Medicare multiple-radiology reduction — base codes 4
  4. Medicare bilateral-surgery adjustment
  5. mid-level provider reduction (by NUCC taxonomy)
  6. modifier 22 present → 135% of the running amount
  7. modifier 52 present → 50% of the running amount
  8. custom SQL — Same global-surgery post-op allocation as hash c5fd5754fcf4a52d (Allowed/GlobalDays*PostOpRate), but hardened: falls back to returning {Allowed} unchanged when GLOB_DAYS or POST_OP is missing/non-numeric/zero instead of dividing by zero. — when Modifier 55 is present
  9. modifier 54 present → 80% of the running amount
  10. modifier 62 present → 62.5% of the running amount
  11. modifier 73 present → 50% of the running amount
  12. modifier 78 present → 70% of the running amount
  13. modifier 80 present → 16% of the running amount
  14. modifier 81 present → 16% of the running amount
  15. modifier 82 present → 16% of the running amount
  16. modifier AS present → 14% of the running amount
  17. modifier QY present → 50% of the running amount
  18. modifier QK present → 50% of the running amount
  19. modifier QX present → 50% of the running amount
  20. cap each charge and the account total at 100% of billed charges
160% Medicare - No Sequestration7 base · 20 adj
Custom Design
Profee · CVP_MIDWEST, NOVUS, RS_OHIO · 2023-01-01 → 2999-12-31
Humana
Profee · CVP_MIDWEST, NOVUS, RS_OHIO · 2021-05-01 → 2024-07-31
Base terms — first match wins
  1. flat $0 — when NoncoverageStatus Noncovered is present
  2. 160% of Medicare lab
  3. 100% of Medicare drug
  4. 160% of Medicare DME
  5. 160% of Medicare RVU — when PlaceOfService 2 is present
  6. 160% of Medicare RVU
  7. 0% of billed charges
Adjustments — all apply, in order
  1. Medicare multiple-procedure reduction — base codes 2, 3; pays 100/50% — when Modifier 55 is absent; Modifier 82 is absent
  2. Medicare multiple-endoscopy reduction
  3. Medicare multiple-radiology reduction — base codes 4
  4. Medicare bilateral-surgery adjustment
  5. mid-level provider reduction (by NUCC taxonomy)
  6. modifier 22 present → 135% of the running amount
  7. modifier 52 present → 50% of the running amount
  8. custom SQL — Same global-surgery post-op allocation as hash c5fd5754fcf4a52d (Allowed/GlobalDays*PostOpRate), but hardened: falls back to returning {Allowed} unchanged when GLOB_DAYS or POST_OP is missing/non-numeric/zero instead of dividing by zero. — when Modifier 55 is present
  9. modifier 54 present → 80% of the running amount
  10. modifier 62 present → 62.5% of the running amount
  11. modifier 73 present → 50% of the running amount
  12. modifier 78 present → 70% of the running amount
  13. modifier 80 present → 16% of the running amount
  14. modifier 81 present → 16% of the running amount
  15. modifier 82 present → 16% of the running amount
  16. modifier AS present → 14% of the running amount
  17. modifier QY present → 50% of the running amount
  18. modifier QK present → 50% of the running amount
  19. modifier QX present → 50% of the running amount
  20. cap each charge and the account total at 100% of billed charges
160%-Medicare-ASC - No Sequestration3 base · 21 adj
Humana
Facility · CVP_MIDWEST, NOVUS, RS_OHIO · 2023-01-01 → 2999-12-31
Base terms — first match wins
  1. flat $0 — when NoncoverageStatus Noncovered is present
  2. 160% of Medicare ASC
  3. flat $0
Adjustments — all apply, in order
  1. multiple-surgery reduction (contract rules) — pays 100/50%
  2. Medicare multiple-procedure reduction — base codes 2; pays 100/50%
  3. Medicare multiple-endoscopy reduction
  4. Medicare multiple-radiology reduction — base codes 4
  5. Medicare bilateral-surgery adjustment
  6. mid-level provider reduction (by NUCC taxonomy)
  7. modifier 22 present → 135% of the running amount
  8. modifier 52 present → 50% of the running amount
  9. custom SQL — Same global-surgery post-op allocation as hash c5fd5754fcf4a52d (Allowed/GlobalDays*PostOpRate), but hardened: falls back to returning {Allowed} unchanged when GLOB_DAYS or POST_OP is missing/non-numeric/zero instead of dividing by zero. — when Modifier 55 is present
  10. modifier 54 present → 80% of the running amount
  11. modifier 62 present → 62.5% of the running amount
  12. modifier 73 present → 50% of the running amount
  13. modifier 78 present → 70% of the running amount
  14. modifier 80 present → 16% of the running amount
  15. modifier 81 present → 16% of the running amount
  16. modifier 82 present → 16% of the running amount
  17. modifier AS present → 14% of the running amount
  18. modifier QY present → 50% of the running amount
  19. modifier QK present → 50% of the running amount
  20. modifier QX present → 50% of the running amount
  21. cap each charge and the account total at 100% of billed charges
162% Medicare7 base · 20 adj
ClaimDOC
Profee · CVP_MIDWEST, NOVUS, RS_OHIO · 2023-01-01 → 2999-12-31
Base terms — first match wins
  1. flat $0 — when NoncoverageStatus Noncovered is present
  2. 162% of Medicare lab
  3. 100% of Medicare drug
  4. 162% of Medicare DME
  5. 162% of Medicare RVU — when PlaceOfService 2 is present
  6. 162% of Medicare RVU
  7. 0% of billed charges
Adjustments — all apply, in order
  1. Medicare multiple-procedure reduction — base codes 2, 3; pays 100/50% — when Modifier 55 is absent; Modifier 82 is absent
  2. Medicare multiple-endoscopy reduction
  3. Medicare multiple-radiology reduction — base codes 4
  4. Medicare bilateral-surgery adjustment
  5. mid-level provider reduction (by NUCC taxonomy)
  6. modifier 22 present → 135% of the running amount
  7. modifier 52 present → 50% of the running amount
  8. custom SQL — Same global-surgery post-op allocation as hash c5fd5754fcf4a52d (Allowed/GlobalDays*PostOpRate), but hardened: falls back to returning {Allowed} unchanged when GLOB_DAYS or POST_OP is missing/non-numeric/zero instead of dividing by zero. — when Modifier 55 is present
  9. modifier 54 present → 80% of the running amount
  10. modifier 62 present → 62.5% of the running amount
  11. modifier 73 present → 50% of the running amount
  12. modifier 78 present → 70% of the running amount
  13. modifier 80 present → 16% of the running amount
  14. modifier 81 present → 16% of the running amount
  15. modifier 82 present → 16% of the running amount
  16. modifier AS present → 14% of the running amount
  17. modifier QY present → 50% of the running amount
  18. modifier QK present → 50% of the running amount
  19. modifier QX present → 50% of the running amount
  20. cap each charge and the account total at 100% of billed charges
163% Medicare - No Sequestration7 base · 20 adj
Humana
Profee · CVP_MIDWEST, NOVUS, RS_OHIO · 2024-08-01 → 2999-12-31
Base terms — first match wins
  1. flat $0 — when NoncoverageStatus Noncovered is present
  2. 163% of Medicare lab
  3. 100% of Medicare drug
  4. 163% of Medicare DME
  5. 163% of Medicare RVU — when PlaceOfService 2 is present
  6. 163% of Medicare RVU
  7. 0% of billed charges
Adjustments — all apply, in order
  1. Medicare multiple-procedure reduction — base codes 2, 3; pays 100/50% — when Modifier 55 is absent; Modifier 82 is absent
  2. Medicare multiple-endoscopy reduction
  3. Medicare multiple-radiology reduction — base codes 4
  4. Medicare bilateral-surgery adjustment
  5. mid-level provider reduction (by NUCC taxonomy)
  6. modifier 22 present → 135% of the running amount
  7. modifier 52 present → 50% of the running amount
  8. custom SQL — Same global-surgery post-op allocation as hash c5fd5754fcf4a52d (Allowed/GlobalDays*PostOpRate), but hardened: falls back to returning {Allowed} unchanged when GLOB_DAYS or POST_OP is missing/non-numeric/zero instead of dividing by zero. — when Modifier 55 is present
  9. modifier 54 present → 80% of the running amount
  10. modifier 62 present → 62.5% of the running amount
  11. modifier 73 present → 50% of the running amount
  12. modifier 78 present → 70% of the running amount
  13. modifier 80 present → 16% of the running amount
  14. modifier 81 present → 16% of the running amount
  15. modifier 82 present → 16% of the running amount
  16. modifier AS present → 14% of the running amount
  17. modifier QY present → 50% of the running amount
  18. modifier QK present → 50% of the running amount
  19. modifier QX present → 50% of the running amount
  20. cap each charge and the account total at 100% of billed charges
165% Medicare7 base · 20 adj
Health2Business
Profee · CVP_MIDWEST, NOVUS, RS_OHIO · 2023-01-01 → 2999-12-31
Base terms — first match wins
  1. flat $0 — when NoncoverageStatus Noncovered is present
  2. 165% of Medicare lab
  3. 100% of Medicare drug
  4. 165% of Medicare DME
  5. 165% of Medicare RVU — when PlaceOfService 2 is present
  6. 165% of Medicare RVU
  7. 0% of billed charges
Adjustments — all apply, in order
  1. Medicare multiple-procedure reduction — base codes 2, 3; pays 100/50% — when Modifier 55 is absent; Modifier 82 is absent
  2. Medicare multiple-endoscopy reduction
  3. Medicare multiple-radiology reduction — base codes 4
  4. Medicare bilateral-surgery adjustment
  5. mid-level provider reduction (by NUCC taxonomy)
  6. modifier 22 present → 135% of the running amount
  7. modifier 52 present → 50% of the running amount
  8. custom SQL — Same global-surgery post-op allocation as hash c5fd5754fcf4a52d (Allowed/GlobalDays*PostOpRate), but hardened: falls back to returning {Allowed} unchanged when GLOB_DAYS or POST_OP is missing/non-numeric/zero instead of dividing by zero. — when Modifier 55 is present
  9. modifier 54 present → 80% of the running amount
  10. modifier 62 present → 62.5% of the running amount
  11. modifier 73 present → 50% of the running amount
  12. modifier 78 present → 70% of the running amount
  13. modifier 80 present → 16% of the running amount
  14. modifier 81 present → 16% of the running amount
  15. modifier 82 present → 16% of the running amount
  16. modifier AS present → 14% of the running amount
  17. modifier QY present → 50% of the running amount
  18. modifier QK present → 50% of the running amount
  19. modifier QX present → 50% of the running amount
  20. cap each charge and the account total at 100% of billed charges
170% Medicare7 base · 20 adj
Imagine Health
Profee · CVP_MIDWEST, NOVUS, RS_OHIO · 2022-03-01 → 2999-12-31
Base terms — first match wins
  1. flat $0 — when NoncoverageStatus Noncovered is present
  2. 170% of Medicare lab
  3. 100% of Medicare drug
  4. 170% of Medicare DME
  5. 170% of Medicare RVU — when PlaceOfService 2 is present
  6. 170% of Medicare RVU
  7. 0% of billed charges
Adjustments — all apply, in order
  1. Medicare multiple-procedure reduction — base codes 2, 3; pays 100/50% — when Modifier 55 is absent; Modifier 82 is absent
  2. Medicare multiple-endoscopy reduction
  3. Medicare multiple-radiology reduction — base codes 4
  4. Medicare bilateral-surgery adjustment
  5. mid-level provider reduction (by NUCC taxonomy)
  6. modifier 22 present → 135% of the running amount
  7. modifier 52 present → 50% of the running amount
  8. custom SQL — Same global-surgery post-op allocation as hash c5fd5754fcf4a52d (Allowed/GlobalDays*PostOpRate), but hardened: falls back to returning {Allowed} unchanged when GLOB_DAYS or POST_OP is missing/non-numeric/zero instead of dividing by zero. — when Modifier 55 is present
  9. modifier 54 present → 80% of the running amount
  10. modifier 62 present → 62.5% of the running amount
  11. modifier 73 present → 50% of the running amount
  12. modifier 78 present → 70% of the running amount
  13. modifier 80 present → 16% of the running amount
  14. modifier 81 present → 16% of the running amount
  15. modifier 82 present → 16% of the running amount
  16. modifier AS present → 14% of the running amount
  17. modifier QY present → 50% of the running amount
  18. modifier QK present → 50% of the running amount
  19. modifier QX present → 50% of the running amount
  20. cap each charge and the account total at 100% of billed charges
175% Medicare7 base · 20 adj
Oscar
Profee · CVP_MIDWEST, NOVUS, RS_OHIO · 2022-03-08 → 2999-12-31
Med Ben Administrators
Profee · CVP_MIDWEST, NOVUS, RS_OHIO · 2022-03-08 → 2999-12-31
Base terms — first match wins
  1. flat $0 — when NoncoverageStatus Noncovered is present
  2. 175% of Medicare lab
  3. 100% of Medicare drug
  4. 175% of Medicare DME
  5. 175% of Medicare RVU — when PlaceOfService 2 is present
  6. 175% of Medicare RVU
  7. 0% of billed charges
Adjustments — all apply, in order
  1. Medicare multiple-procedure reduction — base codes 2, 3; pays 100/50% — when Modifier 55 is absent; Modifier 82 is absent
  2. Medicare multiple-endoscopy reduction
  3. Medicare multiple-radiology reduction — base codes 4
  4. Medicare bilateral-surgery adjustment
  5. mid-level provider reduction (by NUCC taxonomy)
  6. modifier 22 present → 135% of the running amount
  7. modifier 52 present → 50% of the running amount
  8. custom SQL — Same global-surgery post-op allocation as hash c5fd5754fcf4a52d (Allowed/GlobalDays*PostOpRate), but hardened: falls back to returning {Allowed} unchanged when GLOB_DAYS or POST_OP is missing/non-numeric/zero instead of dividing by zero. — when Modifier 55 is present
  9. modifier 54 present → 80% of the running amount
  10. modifier 62 present → 62.5% of the running amount
  11. modifier 73 present → 50% of the running amount
  12. modifier 78 present → 70% of the running amount
  13. modifier 80 present → 16% of the running amount
  14. modifier 81 present → 16% of the running amount
  15. modifier 82 present → 16% of the running amount
  16. modifier AS present → 14% of the running amount
  17. modifier QY present → 50% of the running amount
  18. modifier QK present → 50% of the running amount
  19. modifier QX present → 50% of the running amount
  20. cap each charge and the account total at 100% of billed charges
180% Medicare7 base · 20 adj
6 Degrees
Profee · CVP_MIDWEST, NOVUS, RS_OHIO · 2021-03-23 → 2999-12-31
Base terms — first match wins
  1. flat $0 — when NoncoverageStatus Noncovered is present
  2. 180% of Medicare lab
  3. 100% of Medicare drug
  4. 180% of Medicare DME
  5. 180% of Medicare RVU — when PlaceOfService 2 is present
  6. 180% of Medicare RVU
  7. 0% of billed charges
Adjustments — all apply, in order
  1. Medicare multiple-procedure reduction — base codes 2, 3; pays 100/50% — when Modifier 55 is absent; Modifier 82 is absent
  2. Medicare multiple-endoscopy reduction
  3. Medicare multiple-radiology reduction — base codes 4
  4. Medicare bilateral-surgery adjustment
  5. mid-level provider reduction (by NUCC taxonomy)
  6. modifier 22 present → 135% of the running amount
  7. modifier 52 present → 50% of the running amount
  8. custom SQL — Same global-surgery post-op allocation as hash c5fd5754fcf4a52d (Allowed/GlobalDays*PostOpRate), but hardened: falls back to returning {Allowed} unchanged when GLOB_DAYS or POST_OP is missing/non-numeric/zero instead of dividing by zero. — when Modifier 55 is present
  9. modifier 54 present → 80% of the running amount
  10. modifier 62 present → 62.5% of the running amount
  11. modifier 73 present → 50% of the running amount
  12. modifier 78 present → 70% of the running amount
  13. modifier 80 present → 16% of the running amount
  14. modifier 81 present → 16% of the running amount
  15. modifier 82 present → 16% of the running amount
  16. modifier AS present → 14% of the running amount
  17. modifier QY present → 50% of the running amount
  18. modifier QK present → 50% of the running amount
  19. modifier QX present → 50% of the running amount
  20. cap each charge and the account total at 100% of billed charges
95% Medicare7 base · 20 adj
Banner Medicare HMO/PPO
Profee · ARIZONA_EYE · 2024-01-01 → 2999-12-31
Multiplan Medicare
Profee · LargoASC · 2024-06-01 → 2999-12-31
United Healthcare Medicare
Profee · RAK · 2024-01-01 → 2025-01-31
UHC Optum
Profee · ARIZONA_EYE · 2021-01-01 → 2999-12-31
Base terms — first match wins
  1. flat $0 — when NoncoverageStatus Noncovered is present
  2. 95% of Medicare lab
  3. 100% of Medicare drug
  4. 95% of Medicare DME
  5. 95% of Medicare RVU — when PlaceOfService 2 is present
  6. 95% of Medicare RVU
  7. 0% of billed charges
Adjustments — all apply, in order
  1. Medicare multiple-procedure reduction — base codes 2, 3; pays 100/50% — when Modifier 55 is absent; Modifier 82 is absent
  2. Medicare multiple-endoscopy reduction
  3. Medicare multiple-radiology reduction — base codes 4
  4. Medicare bilateral-surgery adjustment
  5. mid-level provider reduction (by NUCC taxonomy)
  6. modifier 22 present → 135% of the running amount
  7. modifier 52 present → 50% of the running amount
  8. custom SQL — Same global-surgery post-op allocation as hash c5fd5754fcf4a52d (Allowed/GlobalDays*PostOpRate), but hardened: falls back to returning {Allowed} unchanged when GLOB_DAYS or POST_OP is missing/non-numeric/zero instead of dividing by zero. — when Modifier 55 is present
  9. modifier 54 present → 80% of the running amount
  10. modifier 62 present → 62.5% of the running amount
  11. modifier 73 present → 50% of the running amount
  12. modifier 78 present → 70% of the running amount
  13. modifier 80 present → 16% of the running amount
  14. modifier 81 present → 16% of the running amount
  15. modifier 82 present → 16% of the running amount
  16. modifier AS present → 14% of the running amount
  17. modifier QY present → 50% of the running amount
  18. modifier QK present → 50% of the running amount
  19. modifier QX present → 50% of the running amount
  20. cap each charge and the account total at 100% of billed charges
95% Medicare - No Sequestration7 base · 20 adj
Cigna
Profee · LargoASC · 2024-06-01 → 2999-12-31
Base terms — first match wins
  1. flat $0 — when NoncoverageStatus Noncovered is present
  2. 95% of Medicare lab
  3. 100% of Medicare drug
  4. 95% of Medicare DME
  5. 95% of Medicare RVU — when PlaceOfService 2 is present
  6. 95% of Medicare RVU
  7. 0% of billed charges
Adjustments — all apply, in order
  1. Medicare multiple-procedure reduction — base codes 2, 3; pays 100/50% — when Modifier 55 is absent; Modifier 82 is absent
  2. Medicare multiple-endoscopy reduction
  3. Medicare multiple-radiology reduction — base codes 4
  4. Medicare bilateral-surgery adjustment
  5. mid-level provider reduction (by NUCC taxonomy)
  6. modifier 22 present → 135% of the running amount
  7. modifier 52 present → 50% of the running amount
  8. custom SQL — Same global-surgery post-op allocation as hash c5fd5754fcf4a52d (Allowed/GlobalDays*PostOpRate), but hardened: falls back to returning {Allowed} unchanged when GLOB_DAYS or POST_OP is missing/non-numeric/zero instead of dividing by zero. — when Modifier 55 is present
  9. modifier 54 present → 80% of the running amount
  10. modifier 62 present → 62.5% of the running amount
  11. modifier 73 present → 50% of the running amount
  12. modifier 78 present → 70% of the running amount
  13. modifier 80 present → 16% of the running amount
  14. modifier 81 present → 16% of the running amount
  15. modifier 82 present → 16% of the running amount
  16. modifier AS present → 14% of the running amount
  17. modifier QY present → 50% of the running amount
  18. modifier QK present → 50% of the running amount
  19. modifier QX present → 50% of the running amount
  20. cap each charge and the account total at 100% of billed charges
95% Medicare - OphthalmologyAdj7 base · 21 adj
Anthem Medicare
Profee · RAK · 2021-01-01 → 2024-08-31
Anthem Medicare
Profee · MCPEAK · 2023-01-01 → 2999-12-31
Base terms — first match wins
  1. flat $0 — when NoncoverageStatus Noncovered is present
  2. 95% of Medicare lab
  3. 100% of Medicare drug
  4. 95% of Medicare DME
  5. 95% of Medicare RVU — when PlaceOfService 2 is present
  6. 95% of Medicare RVU
  7. 0% of billed charges
Adjustments — all apply, in order
  1. Medicare multiple-procedure reduction — base codes 2, 3; pays 100/50% — when Modifier 55 is absent; Modifier 82 is absent
  2. Medicare multiple-ophthalmology reduction — base codes 7; pays 100/80%
  3. Medicare multiple-endoscopy reduction
  4. Medicare multiple-radiology reduction — base codes 4
  5. Medicare bilateral-surgery adjustment
  6. mid-level provider reduction (by NUCC taxonomy)
  7. modifier 22 present → 135% of the running amount
  8. modifier 52 present → 50% of the running amount
  9. custom SQL — Same global-surgery post-op allocation as hash c5fd5754fcf4a52d (Allowed/GlobalDays*PostOpRate), but hardened: falls back to returning {Allowed} unchanged when GLOB_DAYS or POST_OP is missing/non-numeric/zero instead of dividing by zero. — when Modifier 55 is present
  10. modifier 54 present → 80% of the running amount
  11. modifier 62 present → 62.5% of the running amount
  12. modifier 73 present → 50% of the running amount
  13. modifier 78 present → 70% of the running amount
  14. modifier 80 present → 16% of the running amount
  15. modifier 81 present → 16% of the running amount
  16. modifier 82 present → 16% of the running amount
  17. modifier AS present → 14% of the running amount
  18. modifier QY present → 50% of the running amount
  19. modifier QK present → 50% of the running amount
  20. modifier QX present → 50% of the running amount
  21. cap each charge and the account total at 100% of billed charges
95% Medicare - OphthalmologyAdj - Aetna7 base · 21 adj
Aetna Medicare
Profee · STILES · 2023-01-01 → 2999-12-31
Base terms — first match wins
  1. flat $0 — when NoncoverageStatus Noncovered is present
  2. 95% of Medicare lab
  3. 100% of Medicare drug
  4. 95% of Medicare DME
  5. 95% of Medicare RVU — when PlaceOfService 2 is present
  6. 95% of Medicare RVU
  7. 0% of billed charges
Adjustments — all apply, in order
  1. Medicare multiple-procedure reduction — base codes 2, 3; pays 100/50/25% — when Modifier 55 is absent; Modifier 82 is absent
  2. Medicare multiple-ophthalmology reduction — base codes 7; pays 100/80%
  3. Medicare multiple-endoscopy reduction
  4. Medicare multiple-radiology reduction — base codes 4
  5. Medicare bilateral-surgery adjustment
  6. mid-level provider reduction (by NUCC taxonomy)
  7. modifier 22 present → 135% of the running amount
  8. modifier 52 present → 50% of the running amount
  9. custom SQL — Same global-surgery post-op allocation as hash c5fd5754fcf4a52d (Allowed/GlobalDays*PostOpRate), but hardened: falls back to returning {Allowed} unchanged when GLOB_DAYS or POST_OP is missing/non-numeric/zero instead of dividing by zero. — when Modifier 55 is present
  10. modifier 54 present → 80% of the running amount
  11. modifier 62 present → 62.5% of the running amount
  12. modifier 73 present → 50% of the running amount
  13. modifier 78 present → 70% of the running amount
  14. modifier 80 present → 16% of the running amount
  15. modifier 81 present → 16% of the running amount
  16. modifier 82 present → 16% of the running amount
  17. modifier AS present → 14% of the running amount
  18. modifier QY present → 50% of the running amount
  19. modifier QK present → 50% of the running amount
  20. modifier QX present → 50% of the running amount
  21. cap each charge and the account total at 100% of billed charges
95% Medicare 50% Lab7 base · 20 adj
Humana Medicare
Profee · ARIZONA_EYE · 2023-01-01 → 2999-12-31
Humana Medicare
Profee · HOLCOMB · 2023-01-01 → 2999-12-31
Base terms — first match wins
  1. flat $0 — when NoncoverageStatus Noncovered is present
  2. 50% of Medicare lab
  3. 100% of Medicare drug
  4. 95% of Medicare DME
  5. 95% of Medicare RVU — when PlaceOfService 2 is present
  6. 95% of Medicare RVU
  7. 0% of billed charges
Adjustments — all apply, in order
  1. Medicare multiple-procedure reduction — base codes 2, 3; pays 100/50% — when Modifier 55 is absent; Modifier 82 is absent
  2. Medicare multiple-endoscopy reduction
  3. Medicare multiple-radiology reduction — base codes 4
  4. Medicare bilateral-surgery adjustment
  5. mid-level provider reduction (by NUCC taxonomy)
  6. modifier 22 present → 135% of the running amount
  7. modifier 52 present → 50% of the running amount
  8. custom SQL — Same global-surgery post-op allocation as hash c5fd5754fcf4a52d (Allowed/GlobalDays*PostOpRate), but hardened: falls back to returning {Allowed} unchanged when GLOB_DAYS or POST_OP is missing/non-numeric/zero instead of dividing by zero. — when Modifier 55 is present
  9. modifier 54 present → 80% of the running amount
  10. modifier 62 present → 62.5% of the running amount
  11. modifier 73 present → 50% of the running amount
  12. modifier 78 present → 70% of the running amount
  13. modifier 80 present → 16% of the running amount
  14. modifier 81 present → 16% of the running amount
  15. modifier 82 present → 16% of the running amount
  16. modifier AS present → 14% of the running amount
  17. modifier QY present → 50% of the running amount
  18. modifier QK present → 50% of the running amount
  19. modifier QX present → 50% of the running amount
  20. cap each charge and the account total at 100% of billed charges
95%-Medicare-ASC3 base · 21 adj
Cigna
Facility · LargoASC · 2024-06-01 → 2999-12-31
Base terms — first match wins
  1. flat $0 — when NoncoverageStatus Noncovered is present
  2. 95% of Medicare ASC
  3. flat $0
Adjustments — all apply, in order
  1. multiple-surgery reduction (contract rules) — pays 100/50%
  2. Medicare multiple-procedure reduction — base codes 2; pays 100/50%
  3. Medicare multiple-endoscopy reduction
  4. Medicare multiple-radiology reduction — base codes 4
  5. Medicare bilateral-surgery adjustment
  6. mid-level provider reduction (by NUCC taxonomy)
  7. modifier 22 present → 135% of the running amount
  8. modifier 52 present → 50% of the running amount
  9. custom SQL — Same global-surgery post-op allocation as hash c5fd5754fcf4a52d (Allowed/GlobalDays*PostOpRate), but hardened: falls back to returning {Allowed} unchanged when GLOB_DAYS or POST_OP is missing/non-numeric/zero instead of dividing by zero. — when Modifier 55 is present
  10. modifier 54 present → 80% of the running amount
  11. modifier 62 present → 62.5% of the running amount
  12. modifier 73 present → 50% of the running amount
  13. modifier 78 present → 70% of the running amount
  14. modifier 80 present → 16% of the running amount
  15. modifier 81 present → 16% of the running amount
  16. modifier 82 present → 16% of the running amount
  17. modifier AS present → 14% of the running amount
  18. modifier QY present → 50% of the running amount
  19. modifier QK present → 50% of the running amount
  20. modifier QX present → 50% of the running amount
  21. cap each charge and the account total at 100% of billed charges
97% Medicare7 base · 20 adj
Complete Health ACO
Profee · AVC_ALABAMA · 2023-01-01 → 2025-04-30
Base terms — first match wins
  1. flat $0 — when NoncoverageStatus Noncovered is present
  2. 97% of Medicare lab
  3. 100% of Medicare drug
  4. 97% of Medicare DME
  5. 97% of Medicare RVU — when PlaceOfService 2 is present
  6. 97% of Medicare RVU
  7. 0% of billed charges
Adjustments — all apply, in order
  1. Medicare multiple-procedure reduction — base codes 2, 3; pays 100/50% — when Modifier 55 is absent; Modifier 82 is absent
  2. Medicare multiple-endoscopy reduction
  3. Medicare multiple-radiology reduction — base codes 4
  4. Medicare bilateral-surgery adjustment
  5. mid-level provider reduction (by NUCC taxonomy)
  6. modifier 22 present → 135% of the running amount
  7. modifier 52 present → 50% of the running amount
  8. custom SQL — Same global-surgery post-op allocation as hash c5fd5754fcf4a52d (Allowed/GlobalDays*PostOpRate), but hardened: falls back to returning {Allowed} unchanged when GLOB_DAYS or POST_OP is missing/non-numeric/zero instead of dividing by zero. — when Modifier 55 is present
  9. modifier 54 present → 80% of the running amount
  10. modifier 62 present → 62.5% of the running amount
  11. modifier 73 present → 50% of the running amount
  12. modifier 78 present → 70% of the running amount
  13. modifier 80 present → 16% of the running amount
  14. modifier 81 present → 16% of the running amount
  15. modifier 82 present → 16% of the running amount
  16. modifier AS present → 14% of the running amount
  17. modifier QY present → 50% of the running amount
  18. modifier QK present → 50% of the running amount
  19. modifier QX present → 50% of the running amount
  20. cap each charge and the account total at 100% of billed charges
98% Medicare7 base · 21 adj
Aetna
Profee · LargoASC · 2024-05-01 → 2025-04-30
Base terms — first match wins
  1. flat $0 — when NoncoverageStatus Noncovered is present
  2. 98% of Medicare lab
  3. 100% of Medicare drug
  4. 98% of Medicare DME
  5. 98% of Medicare RVU — when PlaceOfService 2 is present
  6. 98% of Medicare RVU
  7. 0% of billed charges
Adjustments — all apply, in order
  1. Medicare multiple-procedure reduction — base codes 2, 3; pays 100/50/25% — when Modifier 55 is absent; Modifier 82 is absent
  2. Medicare multiple-ophthalmology reduction — base codes 7; pays 100/80%
  3. Medicare multiple-endoscopy reduction
  4. Medicare multiple-radiology reduction — base codes 4
  5. Medicare bilateral-surgery adjustment
  6. mid-level provider reduction (by NUCC taxonomy)
  7. modifier 22 present → 135% of the running amount
  8. modifier 52 present → 50% of the running amount
  9. custom SQL — Same global-surgery post-op allocation as hash c5fd5754fcf4a52d (Allowed/GlobalDays*PostOpRate), but hardened: falls back to returning {Allowed} unchanged when GLOB_DAYS or POST_OP is missing/non-numeric/zero instead of dividing by zero. — when Modifier 55 is present
  10. modifier 54 present → 80% of the running amount
  11. modifier 62 present → 62.5% of the running amount
  12. modifier 73 present → 50% of the running amount
  13. modifier 78 present → 70% of the running amount
  14. modifier 80 present → 16% of the running amount
  15. modifier 81 present → 16% of the running amount
  16. modifier 82 present → 16% of the running amount
  17. modifier AS present → 14% of the running amount
  18. modifier QY present → 50% of the running amount
  19. modifier QK present → 50% of the running amount
  20. modifier QX present → 50% of the running amount
  21. cap each charge and the account total at 100% of billed charges
98%-Medicare-ASC3 base · 22 adj
Aetna
Facility · LargoASC · 2024-05-01 → 2025-04-30
Base terms — first match wins
  1. flat $0 — when NoncoverageStatus Noncovered is present
  2. 98% of Medicare ASC
  3. flat $0
Adjustments — all apply, in order
  1. multiple-surgery reduction (contract rules) — pays 100/50/25%
  2. Medicare multiple-procedure reduction — base codes 2; pays 100/50/25%
  3. Medicare multiple-ophthalmology reduction — base codes 7; pays 100/80%
  4. Medicare multiple-endoscopy reduction
  5. Medicare multiple-radiology reduction — base codes 4
  6. Medicare bilateral-surgery adjustment
  7. mid-level provider reduction (by NUCC taxonomy)
  8. modifier 22 present → 135% of the running amount
  9. modifier 52 present → 50% of the running amount
  10. custom SQL — Same global-surgery post-op allocation as hash c5fd5754fcf4a52d (Allowed/GlobalDays*PostOpRate), but hardened: falls back to returning {Allowed} unchanged when GLOB_DAYS or POST_OP is missing/non-numeric/zero instead of dividing by zero. — when Modifier 55 is present
  11. modifier 54 present → 80% of the running amount
  12. modifier 62 present → 62.5% of the running amount
  13. modifier 73 present → 50% of the running amount
  14. modifier 78 present → 70% of the running amount
  15. modifier 80 present → 16% of the running amount
  16. modifier 81 present → 16% of the running amount
  17. modifier 82 present → 16% of the running amount
  18. modifier AS present → 14% of the running amount
  19. modifier QY present → 50% of the running amount
  20. modifier QK present → 50% of the running amount
  21. modifier QX present → 50% of the running amount
  22. cap each charge and the account total at 100% of billed charges
ARC - Aetna Commercial Profees6 base · 21 adj
Aetna
Profee · ASSOCIATED_RETINAL · 2023-01-01 → 2999-12-31
Base terms — first match wins
  1. flat $0 — when NoncoverageStatus Noncovered is present
  2. 120% of Medicare lab
  3. 120% of Medicare DME
  4. 100% of Medicare drug
  5. 120% of Medicare RVU
  6. 0% of billed charges
Adjustments — all apply, in order
  1. Medicare multiple-procedure reduction — base codes 2, 3; pays 100/50/25% — when Modifier 55 is absent; Modifier 82 is absent
  2. Medicare multiple-ophthalmology reduction — base codes 7; pays 100/80%
  3. Medicare multiple-endoscopy reduction
  4. Medicare multiple-radiology reduction — base codes 4
  5. Medicare bilateral-surgery adjustment
  6. mid-level provider reduction (by NUCC taxonomy)
  7. modifier 22 present → 135% of the running amount
  8. modifier 52 present → 50% of the running amount
  9. custom SQL — Same global-surgery post-op allocation as hash c5fd5754fcf4a52d (Allowed/GlobalDays*PostOpRate), but hardened: falls back to returning {Allowed} unchanged when GLOB_DAYS or POST_OP is missing/non-numeric/zero instead of dividing by zero. — when Modifier 55 is present
  10. modifier 54 present → 80% of the running amount
  11. modifier 62 present → 62.5% of the running amount
  12. modifier 73 present → 50% of the running amount
  13. modifier 78 present → 70% of the running amount
  14. modifier 80 present → 16% of the running amount
  15. modifier 81 present → 16% of the running amount
  16. modifier 82 present → 16% of the running amount
  17. modifier AS present → 14% of the running amount
  18. modifier QY present → 50% of the running amount
  19. modifier QK present → 50% of the running amount
  20. modifier QX present → 50% of the running amount
  21. cap each charge and the account total at 100% of billed charges
ARC-BCBS HMO Profees5 base · 20 adj
BCBS HMO
Profee · ASSOCIATED_RETINAL · 2023-01-01 → 2999-12-31
Base terms — first match wins
  1. flat $0 — when NoncoverageStatus Noncovered is present
  2. 100% of Medicare drug
  3. 100% of the ARC-BCBS-Clinic-Profee-Fees fee schedule — when FacilityType in Clinic
  4. 100% of the ARC-BCBS-Facility-Profee-Fees fee schedule
  5. 65% of billed charges
Adjustments — all apply, in order
  1. Medicare multiple-procedure reduction — base codes 2, 3; pays 100/50% — when Modifier 55 is absent; Modifier 82 is absent
  2. Medicare multiple-endoscopy reduction
  3. Medicare multiple-radiology reduction — base codes 4
  4. Medicare bilateral-surgery adjustment
  5. mid-level provider reduction (by NUCC taxonomy)
  6. modifier 22 present → 135% of the running amount
  7. modifier 52 present → 50% of the running amount
  8. custom SQL — Same global-surgery post-op allocation as hash c5fd5754fcf4a52d (Allowed/GlobalDays*PostOpRate), but hardened: falls back to returning {Allowed} unchanged when GLOB_DAYS or POST_OP is missing/non-numeric/zero instead of dividing by zero. — when Modifier 55 is present
  9. modifier 54 present → 80% of the running amount
  10. modifier 62 present → 62.5% of the running amount
  11. modifier 73 present → 50% of the running amount
  12. modifier 78 present → 70% of the running amount
  13. modifier 80 present → 16% of the running amount
  14. modifier 81 present → 16% of the running amount
  15. modifier 82 present → 16% of the running amount
  16. modifier AS present → 14% of the running amount
  17. modifier QY present → 50% of the running amount
  18. modifier QK present → 50% of the running amount
  19. modifier QX present → 50% of the running amount
  20. cap each charge and the account total at 100% of billed charges
AZ Medicaid - Profees6 base · 20 adj
Medicaid
Profee · AZ · 2024-01-01 → 2999-12-31
BCBS Health Choice, BCBS Health Choice Medicaid
Profee · ARIZONA_EYE, AZ · 2024-01-01 → 2999-12-31
Base terms — first match wins
  1. flat $0 — when NoncoverageStatus Noncovered is present
  2. 58.66% of billed charges — when AZMedicaidBRCode BR is present
  3. 100% of the Fixed-Fees-Drugs fee schedule
  4. 100% of the Fixed-Fees-DME fee schedule
  5. 100% of the Profee-Lab fee schedule
  6. 100% of the Profee-Fees fee schedule
Adjustments — all apply, in order
  1. Medicare multiple-procedure reduction — base codes 2, 3; pays 100/50% — when Modifier 55 is absent; Modifier 82 is absent
  2. Medicare multiple-endoscopy reduction
  3. Medicare multiple-radiology reduction — base codes 4
  4. mid-level provider reduction (by NUCC taxonomy)
  5. modifier 22 present → 135% of the running amount
  6. modifier 50 present → 150% of the running amount
  7. modifier 52 present → 50% of the running amount
  8. custom SQL — Same global-surgery post-op allocation as hash c5fd5754fcf4a52d (Allowed/GlobalDays*PostOpRate), but hardened: falls back to returning {Allowed} unchanged when GLOB_DAYS or POST_OP is missing/non-numeric/zero instead of dividing by zero. — when Modifier 55 is present
  9. modifier 54 present → 80% of the running amount
  10. modifier 62 present → 62.5% of the running amount
  11. modifier 73 present → 50% of the running amount
  12. modifier 78 present → 70% of the running amount
  13. modifier 80 present → 16% of the running amount
  14. modifier 81 present → 16% of the running amount
  15. modifier 82 present → 16% of the running amount
  16. modifier AS present → 14% of the running amount
  17. modifier QY present → 50% of the running amount
  18. modifier QK present → 50% of the running amount
  19. modifier QX present → 50% of the running amount
  20. cap each charge and the account total at 100% of billed charges
AZ-Cigna Profees5 base · 20 adj
Cigna
Profee · ARIZONA_EYE · 2023-01-01 → 2999-12-31
Base terms — first match wins
  1. flat $0 — when NoncoverageStatus Noncovered is present
  2. 100% of Medicare drug
  3. 100% of the AZ-Cigna-Profee-Fees fee schedule — when FacilityType in Clinic
  4. 100% of the AZ-Cigna-Facilty-Profee-Fees fee schedule
  5. 65% of billed charges
Adjustments — all apply, in order
  1. Medicare multiple-procedure reduction — base codes 2, 3; pays 100/50% — when Modifier 55 is absent; Modifier 82 is absent
  2. Medicare multiple-endoscopy reduction
  3. Medicare multiple-radiology reduction — base codes 4
  4. Medicare bilateral-surgery adjustment
  5. mid-level provider reduction (by NUCC taxonomy)
  6. modifier 22 present → 135% of the running amount
  7. modifier 52 present → 50% of the running amount
  8. custom SQL — Same global-surgery post-op allocation as hash c5fd5754fcf4a52d (Allowed/GlobalDays*PostOpRate), but hardened: falls back to returning {Allowed} unchanged when GLOB_DAYS or POST_OP is missing/non-numeric/zero instead of dividing by zero. — when Modifier 55 is present
  9. modifier 54 present → 80% of the running amount
  10. modifier 62 present → 62.5% of the running amount
  11. modifier 73 present → 50% of the running amount
  12. modifier 78 present → 70% of the running amount
  13. modifier 80 present → 16% of the running amount
  14. modifier 81 present → 16% of the running amount
  15. modifier 82 present → 16% of the running amount
  16. modifier AS present → 14% of the running amount
  17. modifier QY present → 50% of the running amount
  18. modifier QK present → 50% of the running amount
  19. modifier QX present → 50% of the running amount
  20. cap each charge and the account total at 100% of billed charges
Aetna3 base · 21 adj
Aetna
Profee · SABATES_EYE · 2018-05-01 → 2999-12-31
Base terms — first match wins
  1. flat $0 — when NoncoverageStatus Noncovered is present
  2. 100% of Medicare drug
  3. 100% of the Profee-Fees fee schedule
Adjustments — all apply, in order
  1. Medicare multiple-procedure reduction — base codes 2, 3; pays 100/50/25% — when Modifier 55 is absent; Modifier 82 is absent
  2. Medicare multiple-ophthalmology reduction — base codes 7; pays 100/80%
  3. Medicare multiple-endoscopy reduction
  4. Medicare multiple-radiology reduction — base codes 4
  5. Medicare bilateral-surgery adjustment
  6. mid-level provider reduction (by NUCC taxonomy)
  7. modifier 22 present → 135% of the running amount
  8. modifier 52 present → 50% of the running amount
  9. custom SQL — Same global-surgery post-op allocation as hash c5fd5754fcf4a52d (Allowed/GlobalDays*PostOpRate), but hardened: falls back to returning {Allowed} unchanged when GLOB_DAYS or POST_OP is missing/non-numeric/zero instead of dividing by zero. — when Modifier 55 is present
  10. modifier 54 present → 80% of the running amount
  11. modifier 62 present → 62.5% of the running amount
  12. modifier 73 present → 50% of the running amount
  13. modifier 78 present → 70% of the running amount
  14. modifier 80 present → 16% of the running amount
  15. modifier 81 present → 16% of the running amount
  16. modifier 82 present → 16% of the running amount
  17. modifier AS present → 14% of the running amount
  18. modifier QY present → 50% of the running amount
  19. modifier QK present → 50% of the running amount
  20. modifier QX present → 50% of the running amount
  21. cap each charge and the account total at 100% of billed charges
Aetna-Medicare-ASC4 base · 22 adj
Aetna Medicare
Facility · CVP_MIDATLANTIC · 2020-01-01 → 2999-12-31
Base terms — first match wins
  1. flat $0 — when NoncoverageStatus Noncovered is present
  2. 100% of Medicare ASC
  3. 100% of Medicare drug
  4. 35% of billed charges
Adjustments — all apply, in order
  1. multiple-surgery reduction (contract rules) — pays 100/50/25%
  2. Medicare multiple-procedure reduction — base codes 2; pays 100/50/25%
  3. Medicare multiple-ophthalmology reduction — base codes 7; pays 100/80%
  4. Medicare multiple-endoscopy reduction
  5. Medicare multiple-radiology reduction — base codes 4
  6. Medicare bilateral-surgery adjustment
  7. mid-level provider reduction (by NUCC taxonomy)
  8. modifier 22 present → 135% of the running amount
  9. modifier 52 present → 50% of the running amount
  10. custom SQL — Same global-surgery post-op allocation as hash c5fd5754fcf4a52d (Allowed/GlobalDays*PostOpRate), but hardened: falls back to returning {Allowed} unchanged when GLOB_DAYS or POST_OP is missing/non-numeric/zero instead of dividing by zero. — when Modifier 55 is present
  11. modifier 54 present → 80% of the running amount
  12. modifier 62 present → 62.5% of the running amount
  13. modifier 73 present → 50% of the running amount
  14. modifier 78 present → 70% of the running amount
  15. modifier 80 present → 16% of the running amount
  16. modifier 81 present → 16% of the running amount
  17. modifier 82 present → 16% of the running amount
  18. modifier AS present → 14% of the running amount
  19. modifier QY present → 50% of the running amount
  20. modifier QK present → 50% of the running amount
  21. modifier QX present → 50% of the running amount
  22. cap each charge and the account total at 100% of billed charges
Aetna-VA-Commercial-Groupers4 base · 21 adj
Aetna
Facility · CVP_MIDATLANTIC, RIV · 2022-01-01 → 2999-12-31
Base terms — first match wins
  1. flat $0 — when NoncoverageStatus Noncovered is present
  2. 100% of billed charges — when ProcedureCode V2785 is present
  3. case rate from Aetna-Grouper-Case-Rate (All-level codes)
  4. flat $962.88
Adjustments — all apply, in order
  1. Medicare multiple-procedure reduction — base codes 2, 3; pays 100/50/25% — when Modifier 55 is absent
  2. Medicare multiple-ophthalmology reduction — base codes 7; pays 100/80%
  3. Medicare multiple-endoscopy reduction
  4. Medicare multiple-radiology reduction — base codes 4
  5. Medicare bilateral-surgery adjustment
  6. mid-level provider reduction (by NUCC taxonomy)
  7. modifier 22 present → 135% of the running amount
  8. modifier 52 present → 50% of the running amount
  9. custom SQL — Same global-surgery post-op allocation as hash c5fd5754fcf4a52d (Allowed/GlobalDays*PostOpRate), but hardened: falls back to returning {Allowed} unchanged when GLOB_DAYS or POST_OP is missing/non-numeric/zero instead of dividing by zero. — when Modifier 55 is present
  10. modifier 54 present → 80% of the running amount
  11. modifier 62 present → 62.5% of the running amount
  12. modifier 73 present → 50% of the running amount
  13. modifier 78 present → 70% of the running amount
  14. modifier 80 present → 16% of the running amount
  15. modifier 81 present → 16% of the running amount
  16. modifier 82 present → 16% of the running amount
  17. modifier AS present → 14% of the running amount
  18. modifier QY present → 50% of the running amount
  19. modifier QK present → 50% of the running amount
  20. modifier QX present → 50% of the running amount
  21. cap each charge and the account total at 100% of billed charges
Anthem-Profee-HMO3 base · 21 adj
Anthem HMO
Profee · RAK, Clinic · 2017-01-01 → 2024-10-31
Anthem HMO
Profee · RAK, ASC, Home, Hospital · 2017-01-01 → 2999-12-31
Base terms — first match wins
  1. flat $0 — when NoncoverageStatus Noncovered is present
  2. 100% of Medicare drug
  3. 100% of the Profee-Fees fee schedule
Adjustments — all apply, in order
  1. Medicare multiple-procedure reduction — base codes 2, 3; pays 100/50% — when Modifier 55 is absent; Modifier 82 is absent
  2. Medicare multiple-ophthalmology reduction — base codes 7; pays 100/80%
  3. Medicare multiple-endoscopy reduction
  4. Medicare multiple-radiology reduction — base codes 4
  5. Medicare bilateral-surgery adjustment
  6. mid-level provider reduction (by NUCC taxonomy)
  7. modifier 22 present → 135% of the running amount
  8. modifier 52 present → 50% of the running amount
  9. custom SQL — Same global-surgery post-op allocation as hash c5fd5754fcf4a52d (Allowed/GlobalDays*PostOpRate), but hardened: falls back to returning {Allowed} unchanged when GLOB_DAYS or POST_OP is missing/non-numeric/zero instead of dividing by zero. — when Modifier 55 is present
  10. modifier 54 present → 80% of the running amount
  11. modifier 62 present → 62.5% of the running amount
  12. modifier 73 present → 50% of the running amount
  13. modifier 78 present → 70% of the running amount
  14. modifier 80 present → 16% of the running amount
  15. modifier 81 present → 16% of the running amount
  16. modifier 82 present → 16% of the running amount
  17. modifier AS present → 14% of the running amount
  18. modifier QY present → 50% of the running amount
  19. modifier QK present → 50% of the running amount
  20. modifier QX present → 50% of the running amount
  21. cap each charge and the account total at 100% of billed charges
Anthem-Profee-PPO3 base · 21 adj
Anthem PPO
Profee · RAK, Clinic · 2017-01-01 → 2024-10-31
Anthem PPO
Profee · RAK, ASC, Home, Hospital · 2017-01-01 → 2999-12-31
Base terms — first match wins
  1. flat $0 — when NoncoverageStatus Noncovered is present
  2. 100% of Medicare drug
  3. 100% of the Anthem PPO Profee Fee Schedules fee schedule
Adjustments — all apply, in order
  1. Medicare multiple-procedure reduction — base codes 2, 3; pays 100/50% — when Modifier 55 is absent; Modifier 82 is absent
  2. Medicare multiple-ophthalmology reduction — base codes 7; pays 100/80%
  3. Medicare multiple-endoscopy reduction
  4. Medicare multiple-radiology reduction — base codes 4
  5. Medicare bilateral-surgery adjustment
  6. mid-level provider reduction (by NUCC taxonomy)
  7. modifier 22 present → 135% of the running amount
  8. modifier 52 present → 50% of the running amount
  9. custom SQL — Same global-surgery post-op allocation as hash c5fd5754fcf4a52d (Allowed/GlobalDays*PostOpRate), but hardened: falls back to returning {Allowed} unchanged when GLOB_DAYS or POST_OP is missing/non-numeric/zero instead of dividing by zero. — when Modifier 55 is present
  10. modifier 54 present → 80% of the running amount
  11. modifier 62 present → 62.5% of the running amount
  12. modifier 73 present → 50% of the running amount
  13. modifier 78 present → 70% of the running amount
  14. modifier 80 present → 16% of the running amount
  15. modifier 81 present → 16% of the running amount
  16. modifier 82 present → 16% of the running amount
  17. modifier AS present → 14% of the running amount
  18. modifier QY present → 50% of the running amount
  19. modifier QK present → 50% of the running amount
  20. modifier QX present → 50% of the running amount
  21. cap each charge and the account total at 100% of billed charges
Anthem-VA-ASC-Commercial6 base · 21 adj
Anthem Commercial Plans, Anthem HMO, Anthem PPO
Facility · CVP_MIDATLANTIC · 2023-01-01 → 2999-12-31
Base terms — first match wins
  1. flat $0 — when NoncoverageStatus Noncovered is present
  2. case rate from CaseRate (All-level codes)
  3. 100% of billed charges — when ChargeStatusIndicator H is present
  4. 100% of Medicare lab
  5. 100% of Medicare DME
  6. 100% of billed charges
Adjustments — all apply, in order
  1. Medicare multiple-procedure reduction — base codes 2, 3; pays 100/50% — when Modifier 55 is absent
  2. Medicare multiple-ophthalmology reduction — base codes 7; pays 100/80%
  3. Medicare multiple-endoscopy reduction
  4. Medicare multiple-radiology reduction — base codes 4
  5. Medicare bilateral-surgery adjustment
  6. mid-level provider reduction (by NUCC taxonomy)
  7. modifier 22 present → 135% of the running amount
  8. modifier 52 present → 50% of the running amount
  9. custom SQL — Same global-surgery post-op allocation as hash c5fd5754fcf4a52d (Allowed/GlobalDays*PostOpRate), but hardened: falls back to returning {Allowed} unchanged when GLOB_DAYS or POST_OP is missing/non-numeric/zero instead of dividing by zero. — when Modifier 55 is present
  10. modifier 54 present → 80% of the running amount
  11. modifier 62 present → 62.5% of the running amount
  12. modifier 73 present → 50% of the running amount
  13. modifier 78 present → 70% of the running amount
  14. modifier 80 present → 16% of the running amount
  15. modifier 81 present → 16% of the running amount
  16. modifier 82 present → 16% of the running amount
  17. modifier AS present → 14% of the running amount
  18. modifier QY present → 50% of the running amount
  19. modifier QK present → 50% of the running amount
  20. modifier QX present → 50% of the running amount
  21. cap each charge and the account total at 100% of billed charges
Anthem-VA-ASC-Health-Exchange6 base · 21 adj
Anthem Exchange
Facility · CVP_MIDATLANTIC · 2023-01-01 → 2999-12-31
Base terms — first match wins
  1. flat $0 — when NoncoverageStatus Noncovered is present
  2. case rate from CaseRate (All-level codes)
  3. 100% of billed charges — when ChargeStatusIndicator H is present
  4. 100% of Medicare lab
  5. 100% of Medicare DME
  6. 100% of billed charges
Adjustments — all apply, in order
  1. Medicare multiple-procedure reduction — base codes 2, 3; pays 100/50% — when Modifier 55 is absent
  2. Medicare multiple-ophthalmology reduction — base codes 7; pays 100/80%
  3. Medicare multiple-endoscopy reduction
  4. Medicare multiple-radiology reduction — base codes 4
  5. Medicare bilateral-surgery adjustment
  6. mid-level provider reduction (by NUCC taxonomy)
  7. modifier 22 present → 135% of the running amount
  8. modifier 52 present → 50% of the running amount
  9. custom SQL — Same global-surgery post-op allocation as hash c5fd5754fcf4a52d (Allowed/GlobalDays*PostOpRate), but hardened: falls back to returning {Allowed} unchanged when GLOB_DAYS or POST_OP is missing/non-numeric/zero instead of dividing by zero. — when Modifier 55 is present
  10. modifier 54 present → 80% of the running amount
  11. modifier 62 present → 62.5% of the running amount
  12. modifier 73 present → 50% of the running amount
  13. modifier 78 present → 70% of the running amount
  14. modifier 80 present → 16% of the running amount
  15. modifier 81 present → 16% of the running amount
  16. modifier 82 present → 16% of the running amount
  17. modifier AS present → 14% of the running amount
  18. modifier QY present → 50% of the running amount
  19. modifier QK present → 50% of the running amount
  20. modifier QX present → 50% of the running amount
  21. cap each charge and the account total at 100% of billed charges
Arizona - UHC Commercial Profees13 base · 21 adj
United Healthcare
Profee · ARIZONA_EYE · 2023-01-01 → 2025-08-31
Base terms — first match wins
  1. flat $0 — when NoncoverageStatus Noncovered is present
  2. 100% of the Carveouts fee schedule
  3. 100% of Medicare drug
  4. computed expression (operands follow)
  5. 100% of the UHC-Category-Multiplier fee schedule
  6. Multiply 100% of Medicare DME (AZ)
  7. computed expression (operands follow)
  8. 100% of the UHC-Category-Multiplier fee schedule
  9. Multiply 100% of Medicare lab (AZ)
  10. computed expression (operands follow)
  11. 100% of the UHC-Category-Multiplier fee schedule
  12. Multiply 100% of Medicare RVU
  13. 35% of billed charges
Adjustments — all apply, in order
  1. Medicare multiple-procedure reduction — base codes 2, 3; pays 100/50% — when Modifier 55 is absent; Modifier 82 is absent
  2. Medicare multiple-endoscopy reduction
  3. Medicare multiple-radiology reduction — base codes 4
  4. Medicare bilateral-surgery adjustment
  5. mid-level provider reduction (by NUCC taxonomy)
  6. modifier 22 present → 135% of the running amount
  7. modifier 52 present → 50% of the running amount
  8. modifier 53 present → 25% of the running amount
  9. custom SQL — Same global-surgery post-op allocation as hash c5fd5754fcf4a52d (Allowed/GlobalDays*PostOpRate), but hardened: falls back to returning {Allowed} unchanged when GLOB_DAYS or POST_OP is missing/non-numeric/zero instead of dividing by zero. — when Modifier 55 is present
  10. modifier 54 present → 80% of the running amount
  11. modifier 62 present → 62.5% of the running amount
  12. modifier 73 present → 50% of the running amount
  13. modifier 78 present → 70% of the running amount
  14. modifier 80 present → 16% of the running amount
  15. modifier 81 present → 16% of the running amount
  16. modifier 82 present → 16% of the running amount
  17. modifier AS present → 14% of the running amount
  18. modifier QY present → 50% of the running amount
  19. modifier QK present → 50% of the running amount
  20. modifier QX present → 50% of the running amount
  21. cap each charge and the account total at 100% of billed charges
Arizona - UHC Commercial Profees 2025-0913 base · 22 adj
United Healthcare
Profee · ARIZONA_EYE · 2025-09-01 → 2999-12-31
Base terms — first match wins
  1. flat $0 — when NoncoverageStatus Noncovered is present
  2. 100% of the Carveouts fee schedule
  3. 100% of Medicare drug
  4. computed expression (operands follow)
  5. 100% of the UHC-Category-Multiplier fee schedule
  6. Multiply 100% of Medicare DME (rates as of 2024-01-01)
  7. computed expression (operands follow)
  8. 100% of the UHC-Category-Multiplier fee schedule
  9. Multiply 100% of Medicare lab (rates as of 2024-01-01)
  10. computed expression (operands follow)
  11. 100% of the UHC-Category-Multiplier fee schedule
  12. Multiply 100% of Medicare RVU (rates as of 2024-01-01)
  13. 20% of billed charges
Adjustments — all apply, in order
  1. Medicare multiple-procedure reduction — base codes 2, 3; pays 100/50% — when Modifier 55 is absent; Modifier 82 is absent
  2. Medicare multiple-endoscopy reduction
  3. Medicare multiple-radiology reduction — base codes 4
  4. Medicare bilateral-surgery adjustment
  5. mid-level provider reduction (by NUCC taxonomy)
  6. modifier 22 present → 135% of the running amount
  7. modifier 52 present → 50% of the running amount
  8. modifier 53 present → 25% of the running amount
  9. custom SQL — Same global-surgery post-op allocation as hash c5fd5754fcf4a52d (Allowed/GlobalDays*PostOpRate), but hardened: falls back to returning {Allowed} unchanged when GLOB_DAYS or POST_OP is missing/non-numeric/zero instead of dividing by zero. — when Modifier 55 is present
  10. modifier 54 present → 80% of the running amount
  11. modifier 62 present → 62.5% of the running amount
  12. modifier 73 present → 50% of the running amount
  13. modifier 78 present → 70% of the running amount
  14. modifier 80 present → 16% of the running amount
  15. modifier 81 present → 16% of the running amount
  16. modifier 82 present → 16% of the running amount
  17. modifier AS present → 14% of the running amount
  18. modifier QY present → 50% of the running amount
  19. modifier QK present → 50% of the running amount
  20. modifier QX present → 50% of the running amount
  21. modifier QZ present → 85% of the running amount
  22. cap each charge and the account total at 100% of billed charges
Arizona - UHC Community Medicare Profees13 base · 21 adj
United Healthcare Community Plan Medicare
Profee · ARIZONA_EYE · 2023-01-01 → 2999-12-31
Base terms — first match wins
  1. flat $0 — when NoncoverageStatus Noncovered is present
  2. 100% of the Carveouts fee schedule
  3. 100% of Medicare drug
  4. computed expression (operands follow)
  5. 100% of the UHC-Category-Multiplier fee schedule
  6. Multiply 100% of Medicare DME (rates as of 2008-01-01)
  7. computed expression (operands follow)
  8. 100% of the UHC-Category-Multiplier fee schedule
  9. Multiply 100% of Medicare lab (AZ, rates as of 2008-01-01)
  10. computed expression (operands follow)
  11. 100% of the UHC-Category-Multiplier fee schedule
  12. Multiply 100% of Medicare RVU (rates as of 2008-01-01)
  13. 40% of billed charges
Adjustments — all apply, in order
  1. Medicare multiple-procedure reduction — base codes 2, 3; pays 100/50% — when Modifier 55 is absent; Modifier 82 is absent
  2. Medicare multiple-endoscopy reduction
  3. Medicare multiple-radiology reduction — base codes 4
  4. Medicare bilateral-surgery adjustment
  5. mid-level provider reduction (by NUCC taxonomy)
  6. modifier 22 present → 135% of the running amount
  7. modifier 52 present → 50% of the running amount
  8. modifier 53 present → 25% of the running amount
  9. custom SQL — Same global-surgery post-op allocation as hash c5fd5754fcf4a52d (Allowed/GlobalDays*PostOpRate), but hardened: falls back to returning {Allowed} unchanged when GLOB_DAYS or POST_OP is missing/non-numeric/zero instead of dividing by zero. — when Modifier 55 is present
  10. modifier 54 present → 80% of the running amount
  11. modifier 62 present → 62.5% of the running amount
  12. modifier 73 present → 50% of the running amount
  13. modifier 78 present → 70% of the running amount
  14. modifier 80 present → 16% of the running amount
  15. modifier 81 present → 16% of the running amount
  16. modifier 82 present → 16% of the running amount
  17. modifier AS present → 14% of the running amount
  18. modifier QY present → 50% of the running amount
  19. modifier QK present → 50% of the running amount
  20. modifier QX present → 50% of the running amount
  21. cap each charge and the account total at 100% of billed charges
Arizona - UHC Medicaid Profees6 base · 21 adj
United Healthcare Medicaid
Profee · ARIZONA_EYE · 2024-01-01 → 2999-12-31
Base terms — first match wins
  1. flat $0 — when NoncoverageStatus Noncovered is present
  2. 58.66% of billed charges — when AZMedicaidBRCode BR is present
  3. 95% of the Fixed-Fees-Drugs fee schedule
  4. 95% of the Fixed-Fees-DME fee schedule
  5. 95% of the Profee-Lab fee schedule
  6. 95% of the Profee-Fees fee schedule
Adjustments — all apply, in order
  1. Medicare multiple-procedure reduction — base codes 2, 3; pays 100/50% — when Modifier 55 is absent; Modifier 82 is absent
  2. Medicare multiple-endoscopy reduction
  3. Medicare multiple-radiology reduction — base codes 4
  4. mid-level provider reduction (by NUCC taxonomy)
  5. modifier 22 present → 135% of the running amount
  6. modifier 50 present → 150% of the running amount
  7. modifier 52 present → 50% of the running amount
  8. modifier 53 present → 25% of the running amount
  9. custom SQL — Same global-surgery post-op allocation as hash c5fd5754fcf4a52d (Allowed/GlobalDays*PostOpRate), but hardened: falls back to returning {Allowed} unchanged when GLOB_DAYS or POST_OP is missing/non-numeric/zero instead of dividing by zero. — when Modifier 55 is present
  10. modifier 54 present → 80% of the running amount
  11. modifier 62 present → 62.5% of the running amount
  12. modifier 73 present → 50% of the running amount
  13. modifier 78 present → 70% of the running amount
  14. modifier 80 present → 16% of the running amount
  15. modifier 81 present → 16% of the running amount
  16. modifier 82 present → 16% of the running amount
  17. modifier AS present → 14% of the running amount
  18. modifier QY present → 50% of the running amount
  19. modifier QK present → 50% of the running amount
  20. modifier QX present → 50% of the running amount
  21. cap each charge and the account total at 100% of billed charges
Arizona - UHC Medicare Profees13 base · 21 adj
United Healthcare AARP Medicare, United Healthcare Medicare
Profee · ARIZONA_EYE · 2023-01-01 → 2999-12-31
Base terms — first match wins
  1. flat $0 — when NoncoverageStatus Noncovered is present
  2. 100% of the Carveouts fee schedule
  3. 100% of Medicare drug
  4. computed expression (operands follow)
  5. 100% of the UHC-Category-Multiplier fee schedule
  6. Multiply 100% of Medicare DME (AZ)
  7. computed expression (operands follow)
  8. 100% of the UHC-Category-Multiplier fee schedule
  9. Multiply 100% of Medicare lab (AZ)
  10. computed expression (operands follow)
  11. 100% of the UHC-Category-Multiplier fee schedule
  12. Multiply 100% of Medicare RVU
  13. 35% of billed charges
Adjustments — all apply, in order
  1. Medicare multiple-procedure reduction — base codes 2, 3; pays 100/50% — when Modifier 55 is absent; Modifier 82 is absent
  2. Medicare multiple-endoscopy reduction
  3. Medicare multiple-radiology reduction — base codes 4
  4. Medicare bilateral-surgery adjustment
  5. mid-level provider reduction (by NUCC taxonomy)
  6. modifier 22 present → 135% of the running amount
  7. modifier 52 present → 50% of the running amount
  8. modifier 53 present → 25% of the running amount
  9. custom SQL — Same global-surgery post-op allocation as hash c5fd5754fcf4a52d (Allowed/GlobalDays*PostOpRate), but hardened: falls back to returning {Allowed} unchanged when GLOB_DAYS or POST_OP is missing/non-numeric/zero instead of dividing by zero. — when Modifier 55 is present
  10. modifier 54 present → 80% of the running amount
  11. modifier 62 present → 62.5% of the running amount
  12. modifier 73 present → 50% of the running amount
  13. modifier 78 present → 70% of the running amount
  14. modifier 80 present → 16% of the running amount
  15. modifier 81 present → 16% of the running amount
  16. modifier 82 present → 16% of the running amount
  17. modifier AS present → 14% of the running amount
  18. modifier QY present → 50% of the running amount
  19. modifier QK present → 50% of the running amount
  20. modifier QX present → 50% of the running amount
  21. cap each charge and the account total at 100% of billed charges
BSV_EyeClinicMI-Aetna Profees7 base · 21 adj
Aetna
Profee · BSV_EyeClinicMichigan · 2023-01-01 → 2999-12-31
Base terms — first match wins
  1. flat $0 — when NoncoverageStatus Noncovered is present
  2. 120% of Medicare lab
  3. 100% of Medicare drug
  4. 120% of Medicare DME
  5. 120% of Medicare RVU — when PlaceOfService 2 is present
  6. 120% of Medicare RVU
  7. 0% of billed charges
Adjustments — all apply, in order
  1. Medicare multiple-procedure reduction — base codes 2, 3; pays 100/50/25% — when Modifier 55 is absent; Modifier 82 is absent
  2. Medicare multiple-ophthalmology reduction — base codes 7; pays 100/80%
  3. Medicare multiple-endoscopy reduction
  4. Medicare multiple-radiology reduction — base codes 4
  5. Medicare bilateral-surgery adjustment
  6. mid-level provider reduction (by NUCC taxonomy)
  7. modifier 22 present → 135% of the running amount
  8. modifier 52 present → 50% of the running amount
  9. custom SQL — Same global-surgery post-op allocation as hash c5fd5754fcf4a52d (Allowed/GlobalDays*PostOpRate), but hardened: falls back to returning {Allowed} unchanged when GLOB_DAYS or POST_OP is missing/non-numeric/zero instead of dividing by zero. — when Modifier 55 is present
  10. modifier 54 present → 80% of the running amount
  11. modifier 62 present → 62.5% of the running amount
  12. modifier 73 present → 50% of the running amount
  13. modifier 78 present → 70% of the running amount
  14. modifier 80 present → 16% of the running amount
  15. modifier 81 present → 16% of the running amount
  16. modifier 82 present → 16% of the running amount
  17. modifier AS present → 14% of the running amount
  18. modifier QY present → 50% of the running amount
  19. modifier QK present → 50% of the running amount
  20. modifier QX present → 50% of the running amount
  21. cap each charge and the account total at 100% of billed charges
CVPMidatlantic-UHC Medicare-Profees16 base · 21 adj
United Healthcare Medicare
Profee · CVP_MIDATLANTIC, RIV · 2023-01-01 → 2999-12-31
Base terms — first match wins
  1. flat $0 — when NoncoverageStatus Noncovered is present
  2. 100% of the Carveouts fee schedule
  3. computed expression (operands follow)
  4. 100% of the UHC-Category-Multiplier fee schedule
  5. Multiply 100% of Medicare drug
  6. computed expression (operands follow)
  7. 100% of the UHC-Category-Multiplier fee schedule
  8. Multiply 100% of Medicare DME (VA)
  9. computed expression (operands follow)
  10. 100% of the UHC-Category-Multiplier fee schedule
  11. Multiply 100% of Medicare lab (VA)
  12. computed expression (operands follow)
  13. 100% of the UHC-Category-Multiplier fee schedule
  14. Multiply 100% of Medicare RVU
  15. 100% of Medicare drug
  16. 35% of billed charges
Adjustments — all apply, in order
  1. Medicare multiple-procedure reduction — base codes 2, 3; pays 100/50% — when Modifier 55 is absent; Modifier 82 is absent
  2. Medicare multiple-endoscopy reduction
  3. Medicare multiple-radiology reduction — base codes 4
  4. Medicare bilateral-surgery adjustment
  5. mid-level provider reduction (by NUCC taxonomy)
  6. modifier 22 present → 135% of the running amount
  7. modifier 52 present → 50% of the running amount
  8. modifier 53 present → 25% of the running amount
  9. custom SQL — Same global-surgery post-op allocation as hash c5fd5754fcf4a52d (Allowed/GlobalDays*PostOpRate), but hardened: falls back to returning {Allowed} unchanged when GLOB_DAYS or POST_OP is missing/non-numeric/zero instead of dividing by zero. — when Modifier 55 is present
  10. modifier 54 present → 80% of the running amount
  11. modifier 62 present → 62.5% of the running amount
  12. modifier 73 present → 50% of the running amount
  13. modifier 78 present → 70% of the running amount
  14. modifier 80 present → 16% of the running amount
  15. modifier 81 present → 16% of the running amount
  16. modifier 82 present → 16% of the running amount
  17. modifier AS present → 14% of the running amount
  18. modifier QY present → 50% of the running amount
  19. modifier QK present → 50% of the running amount
  20. modifier QX present → 50% of the running amount
  21. cap each charge and the account total at 100% of billed charges
CVP_MidAtlantic - Sentara Optima Profees ('23)9 base · 20 adj
Sentara Commercial, Sentara Optima
Profee · CVP_MIDATLANTIC · 2022-09-01 → 2023-08-31
Base terms — first match wins
  1. flat $0 — when NoncoverageStatus Noncovered is present
  2. flat $735 — when ProcedureCode 66984 is present
  3. flat $228 — when ProcedureCode 67028 is present
  4. flat $686 — when ProcedureCode 67228 is present
  5. 120% of Medicare lab (rates as of 2021-01-01)
  6. 100% of Medicare drug
  7. 120% of Medicare DME (rates as of 2021-01-01)
  8. 120% of Medicare RVU (rates as of 2021-01-01)
  9. 0% of billed charges
Adjustments — all apply, in order
  1. Medicare multiple-procedure reduction — base codes 2, 3; pays 100/50% — when Modifier 55 is absent; Modifier 82 is absent
  2. Medicare multiple-endoscopy reduction
  3. Medicare multiple-radiology reduction — base codes 4
  4. Medicare bilateral-surgery adjustment
  5. mid-level provider reduction (by NUCC taxonomy)
  6. modifier 22 present → 135% of the running amount
  7. modifier 52 present → 50% of the running amount
  8. custom SQL — Same global-surgery post-op allocation as hash c5fd5754fcf4a52d (Allowed/GlobalDays*PostOpRate), but hardened: falls back to returning {Allowed} unchanged when GLOB_DAYS or POST_OP is missing/non-numeric/zero instead of dividing by zero. — when Modifier 55 is present
  9. modifier 54 present → 80% of the running amount
  10. modifier 62 present → 62.5% of the running amount
  11. modifier 73 present → 50% of the running amount
  12. modifier 78 present → 70% of the running amount
  13. modifier 80 present → 16% of the running amount
  14. modifier 81 present → 16% of the running amount
  15. modifier 82 present → 16% of the running amount
  16. modifier AS present → 14% of the running amount
  17. modifier QY present → 50% of the running amount
  18. modifier QK present → 50% of the running amount
  19. modifier QX present → 50% of the running amount
  20. cap each charge and the account total at 100% of billed charges
CVP_MidAtlantic - Sentara Optima Profees ('24)9 base · 20 adj
Sentara Commercial, Sentara Optima
Profee · CVP_MIDATLANTIC · 2023-09-01 → 2999-12-31
Base terms — first match wins
  1. flat $0 — when NoncoverageStatus Noncovered is present
  2. flat $762 — when ProcedureCode 66984 is present
  3. flat $160.23 — when ProcedureCode 67028 is present
  4. flat $480 — when ProcedureCode 67228 is present
  5. 122% of Medicare lab (rates as of 2021-01-01)
  6. 100% of Medicare drug
  7. 122% of Medicare DME (rates as of 2021-01-01)
  8. 122% of Medicare RVU (rates as of 2021-01-01)
  9. 0% of billed charges
Adjustments — all apply, in order
  1. Medicare multiple-procedure reduction — base codes 2, 3; pays 100/50% — when Modifier 55 is absent; Modifier 82 is absent
  2. Medicare multiple-endoscopy reduction
  3. Medicare multiple-radiology reduction — base codes 4
  4. Medicare bilateral-surgery adjustment
  5. mid-level provider reduction (by NUCC taxonomy)
  6. modifier 22 present → 135% of the running amount
  7. modifier 52 present → 50% of the running amount
  8. custom SQL — Same global-surgery post-op allocation as hash c5fd5754fcf4a52d (Allowed/GlobalDays*PostOpRate), but hardened: falls back to returning {Allowed} unchanged when GLOB_DAYS or POST_OP is missing/non-numeric/zero instead of dividing by zero. — when Modifier 55 is present
  9. modifier 54 present → 80% of the running amount
  10. modifier 62 present → 62.5% of the running amount
  11. modifier 73 present → 50% of the running amount
  12. modifier 78 present → 70% of the running amount
  13. modifier 80 present → 16% of the running amount
  14. modifier 81 present → 16% of the running amount
  15. modifier 82 present → 16% of the running amount
  16. modifier AS present → 14% of the running amount
  17. modifier QY present → 50% of the running amount
  18. modifier QK present → 50% of the running amount
  19. modifier QX present → 50% of the running amount
  20. cap each charge and the account total at 100% of billed charges
CVP_Midatlantic - Cigna Profees5 base · 20 adj
Cigna, Cigna Marketplace
Profee · CVP_MIDATLANTIC · 2023-01-01 → 2999-12-31
Base terms — first match wins
  1. flat $0 — when NoncoverageStatus Noncovered is present
  2. 100% of Medicare drug
  3. 100% of the CVP_MA-Facility-Profee-Fees fee schedule — when FacilityType in ASC, Hospital, Home
  4. 100% of the CVP_MA-Profee-Fees fee schedule
  5. percent-of-charges, rate read from the Percent of Charges schedule
Adjustments — all apply, in order
  1. Medicare multiple-procedure reduction — base codes 2, 3; pays 100/50% — when Modifier 55 is absent; Modifier 82 is absent
  2. Medicare multiple-endoscopy reduction
  3. Medicare multiple-radiology reduction — base codes 4
  4. Medicare bilateral-surgery adjustment
  5. mid-level provider reduction (by NUCC taxonomy)
  6. modifier 22 present → 135% of the running amount
  7. modifier 52 present → 50% of the running amount
  8. custom SQL — Same global-surgery post-op allocation as hash c5fd5754fcf4a52d (Allowed/GlobalDays*PostOpRate), but hardened: falls back to returning {Allowed} unchanged when GLOB_DAYS or POST_OP is missing/non-numeric/zero instead of dividing by zero. — when Modifier 55 is present
  9. modifier 54 present → 80% of the running amount
  10. modifier 62 present → 62.5% of the running amount
  11. modifier 73 present → 50% of the running amount
  12. modifier 78 present → 70% of the running amount
  13. modifier 80 present → 16% of the running amount
  14. modifier 81 present → 16% of the running amount
  15. modifier 82 present → 16% of the running amount
  16. modifier AS present → 14% of the running amount
  17. modifier QY present → 50% of the running amount
  18. modifier QK present → 50% of the running amount
  19. modifier QX present → 50% of the running amount
  20. cap each charge and the account total at 100% of billed charges
CVP_Midatlantic-Anthem/BCBS Profees (11.15.24)7 base · 22 adj
Anthem Commercial Plans, Anthem Exchange, Anthem Federal, Anthem HMO, Anthem PPO
Profee · CVP_MIDATLANTIC · 2024-11-15 → 2999-12-31
Base terms — first match wins
  1. flat $0 — when NoncoverageStatus Noncovered is present
  2. 100% of the CVP_MA-Profee-Fees fee schedule
  3. 100% of Medicare lab
  4. 100% of Medicare drug
  5. 100% of Medicare DME
  6. 100% of Medicare RVU
  7. 100% of billed charges
Adjustments — all apply, in order
  1. Medicare multiple-procedure reduction — base codes 2, 3; pays 100/50% — when Modifier 55 is absent; Modifier 82 is absent
  2. Medicare multiple-ophthalmology reduction — base codes 7; pays 100/80%
  3. Medicare multiple-endoscopy reduction
  4. Medicare multiple-radiology reduction — base codes 4
  5. Medicare bilateral-surgery adjustment
  6. zero out charges excluded by the Bundling-ProcedureCodes schedule
  7. mid-level provider reduction (by NUCC taxonomy)
  8. modifier 22 present → 135% of the running amount
  9. modifier 52 present → 50% of the running amount
  10. modifier 54 present → 70% of the running amount
  11. custom SQL — Same global-surgery post-op allocation as hash c5fd5754fcf4a52d (Allowed/GlobalDays*PostOpRate), but hardened: falls back to returning {Allowed} unchanged when GLOB_DAYS or POST_OP is missing/non-numeric/zero instead of dividing by zero. — when Modifier 55 is present
  12. modifier 62 present → 62.5% of the running amount
  13. modifier 73 present → 50% of the running amount
  14. modifier 78 present → 70% of the running amount
  15. modifier 80 present → 16% of the running amount
  16. modifier 81 present → 16% of the running amount
  17. modifier 82 present → 16% of the running amount
  18. modifier AS present → 14% of the running amount
  19. modifier QY present → 50% of the running amount
  20. modifier QK present → 50% of the running amount
  21. modifier QX present → 50% of the running amount
  22. cap each charge and the account total at 100% of billed charges
CVP_Midatlantic-Anthem/BCBS Profees (pre 11.15.24)7 base · 21 adj
Anthem Commercial Plans, Anthem Exchange, Anthem HMO, Anthem PPO
Profee · CVP_MIDATLANTIC · 2023-01-01 → 2024-11-14
Base terms — first match wins
  1. flat $0 — when NoncoverageStatus Noncovered is present
  2. 100% of the CVP_MA-Profee-Fees fee schedule
  3. 100% of Medicare lab
  4. 100% of Medicare drug
  5. 100% of Medicare DME
  6. 100% of Medicare RVU
  7. 100% of billed charges
Adjustments — all apply, in order
  1. Medicare multiple-procedure reduction — base codes 2, 3; pays 100/50% — when Modifier 55 is absent; Modifier 82 is absent
  2. Medicare multiple-ophthalmology reduction — base codes 7; pays 100/80%
  3. Medicare multiple-endoscopy reduction
  4. Medicare multiple-radiology reduction — base codes 4
  5. Medicare bilateral-surgery adjustment
  6. mid-level provider reduction (by NUCC taxonomy)
  7. modifier 22 present → 135% of the running amount
  8. modifier 52 present → 50% of the running amount
  9. modifier 54 present → 70% of the running amount
  10. custom SQL — Same global-surgery post-op allocation as hash c5fd5754fcf4a52d (Allowed/GlobalDays*PostOpRate), but hardened: falls back to returning {Allowed} unchanged when GLOB_DAYS or POST_OP is missing/non-numeric/zero instead of dividing by zero. — when Modifier 55 is present
  11. modifier 62 present → 62.5% of the running amount
  12. modifier 73 present → 50% of the running amount
  13. modifier 78 present → 70% of the running amount
  14. modifier 80 present → 16% of the running amount
  15. modifier 81 present → 16% of the running amount
  16. modifier 82 present → 16% of the running amount
  17. modifier AS present → 14% of the running amount
  18. modifier QY present → 50% of the running amount
  19. modifier QK present → 50% of the running amount
  20. modifier QX present → 50% of the running amount
  21. cap each charge and the account total at 100% of billed charges
CataractIOK - UHC Facility Fees2 base · 21 adj
United Healthcare
Facility · CATARACT_IOK · 2023-01-01 → 2999-12-31
Base terms — first match wins
  1. flat $0 — when NoncoverageStatus Noncovered is present
  2. 100% of the Facility-Fees fee schedule
Adjustments — all apply, in order
  1. Medicare multiple-procedure reduction — base codes 2; pays 100/50/25/0%
  2. Medicare multiple-endoscopy reduction
  3. Medicare multiple-radiology reduction — base codes 4
  4. Medicare bilateral-surgery adjustment
  5. mid-level provider reduction (by NUCC taxonomy)
  6. modifier 22 present → 135% of the running amount
  7. modifier 52 present → 50% of the running amount
  8. modifier 53 present → 25% of the running amount
  9. custom SQL — Same global-surgery post-op allocation as hash c5fd5754fcf4a52d (Allowed/GlobalDays*PostOpRate), but hardened: falls back to returning {Allowed} unchanged when GLOB_DAYS or POST_OP is missing/non-numeric/zero instead of dividing by zero. — when Modifier 55 is present
  10. modifier 54 present → 80% of the running amount
  11. modifier 62 present → 62.5% of the running amount
  12. modifier 73 present → 50% of the running amount
  13. modifier 78 present → 70% of the running amount
  14. modifier 80 present → 16% of the running amount
  15. modifier 81 present → 16% of the running amount
  16. modifier 82 present → 16% of the running amount
  17. modifier AS present → 14% of the running amount
  18. modifier QY present → 50% of the running amount
  19. modifier QK present → 50% of the running amount
  20. modifier QX present → 50% of the running amount
  21. cap each charge and the account total at 100% of billed charges
CataractIOK - UHC Medicare Facility Fees5 base · 22 adj
United Healthcare Medicare
Facility · CATARACT_IOK · 2023-01-01 → 2999-12-31
Base terms — first match wins
  1. flat $0 — when NoncoverageStatus Noncovered is present
  2. 25% of billed charges — when ProcedureCode C9399 is present
  3. 100% of the Carveouts fee schedule
  4. 100% of Medicare ASC
  5. flat $0
Adjustments — all apply, in order
  1. multiple-surgery reduction (contract rules) — pays 100/50%
  2. Medicare multiple-procedure reduction — base codes 2; pays 100/50%
  3. Medicare multiple-endoscopy reduction
  4. Medicare multiple-radiology reduction — base codes 4
  5. Medicare bilateral-surgery adjustment
  6. mid-level provider reduction (by NUCC taxonomy)
  7. modifier 22 present → 135% of the running amount
  8. modifier 52 present → 50% of the running amount
  9. modifier 53 present → 25% of the running amount
  10. custom SQL — Same global-surgery post-op allocation as hash c5fd5754fcf4a52d (Allowed/GlobalDays*PostOpRate), but hardened: falls back to returning {Allowed} unchanged when GLOB_DAYS or POST_OP is missing/non-numeric/zero instead of dividing by zero. — when Modifier 55 is present
  11. modifier 54 present → 80% of the running amount
  12. modifier 62 present → 62.5% of the running amount
  13. modifier 73 present → 50% of the running amount
  14. modifier 78 present → 70% of the running amount
  15. modifier 80 present → 16% of the running amount
  16. modifier 81 present → 16% of the running amount
  17. modifier 82 present → 16% of the running amount
  18. modifier AS present → 14% of the running amount
  19. modifier QY present → 50% of the running amount
  20. modifier QK present → 50% of the running amount
  21. modifier QX present → 50% of the running amount
  22. cap each charge and the account total at 100% of billed charges
Cavanaugh - Aetna Medicare Profees6 base · 21 adj
Aetna BetterHealth Medicare, Aetna Medicare
Profee · CAVANAUGH · 2020-01-01 → 2999-12-31
Base terms — first match wins
  1. flat $0 — when NoncoverageStatus Noncovered is present
  2. 95% of Medicare lab
  3. 100% of Medicare drug
  4. 95% of Medicare DME
  5. 95% of Medicare RVU
  6. 0% of billed charges
Adjustments — all apply, in order
  1. Medicare multiple-procedure reduction — base codes 2, 3; pays 100/50/25% — when Modifier 55 is absent; Modifier 82 is absent
  2. Medicare multiple-ophthalmology reduction — base codes 7; pays 100/80%
  3. Medicare multiple-endoscopy reduction
  4. Medicare multiple-radiology reduction — base codes 4
  5. Medicare bilateral-surgery adjustment
  6. mid-level provider reduction (by NUCC taxonomy)
  7. modifier 22 present → 135% of the running amount
  8. modifier 52 present → 50% of the running amount
  9. custom SQL — Same global-surgery post-op allocation as hash c5fd5754fcf4a52d (Allowed/GlobalDays*PostOpRate), but hardened: falls back to returning {Allowed} unchanged when GLOB_DAYS or POST_OP is missing/non-numeric/zero instead of dividing by zero. — when Modifier 55 is present
  10. modifier 54 present → 80% of the running amount
  11. modifier 62 present → 62.5% of the running amount
  12. modifier 73 present → 50% of the running amount
  13. modifier 78 present → 70% of the running amount
  14. modifier 80 present → 16% of the running amount
  15. modifier 81 present → 16% of the running amount
  16. modifier 82 present → 16% of the running amount
  17. modifier AS present → 14% of the running amount
  18. modifier QY present → 50% of the running amount
  19. modifier QK present → 50% of the running amount
  20. modifier QX present → 50% of the running amount
  21. cap each charge and the account total at 100% of billed charges
Charges-Facility2 base · 0 adj
Charges
Facility · all facilities · 2022-01-01 → 2999-12-31
Base terms — first match wins
  1. flat $0 — when NoncoverageStatus Noncovered is present
  2. 100% of the Charges fee schedule
Charges-Profee3 base · 0 adj
Charges
Profee · all facilities · 2022-01-01 → 2999-12-31
Base terms — first match wins
  1. flat $0 — when NoncoverageStatus Noncovered is present
  2. 100% of the Charges fee schedule
  3. 0% of the NoChargeMasterFee fee schedule
Cigna-VA-ASC2 base · 20 adj
Cigna
Facility · CVP_MIDATLANTIC · 2023-01-01 → 2999-12-31
Base terms — first match wins
  1. flat $0 — when NoncoverageStatus Noncovered is present
  2. 110% of Medicare ASC
Adjustments — all apply, in order
  1. Medicare multiple-procedure reduction — base codes 2, 3; pays 100/50% — when Modifier 55 is absent
  2. Medicare multiple-endoscopy reduction
  3. Medicare multiple-radiology reduction — base codes 4
  4. Medicare bilateral-surgery adjustment
  5. mid-level provider reduction (by NUCC taxonomy)
  6. modifier 22 present → 135% of the running amount
  7. modifier 52 present → 50% of the running amount
  8. custom SQL — Same global-surgery post-op allocation as hash c5fd5754fcf4a52d (Allowed/GlobalDays*PostOpRate), but hardened: falls back to returning {Allowed} unchanged when GLOB_DAYS or POST_OP is missing/non-numeric/zero instead of dividing by zero. — when Modifier 55 is present
  9. modifier 54 present → 80% of the running amount
  10. modifier 62 present → 62.5% of the running amount
  11. modifier 73 present → 50% of the running amount
  12. modifier 78 present → 70% of the running amount
  13. modifier 80 present → 16% of the running amount
  14. modifier 81 present → 16% of the running amount
  15. modifier 82 present → 16% of the running amount
  16. modifier AS present → 14% of the running amount
  17. modifier QY present → 50% of the running amount
  18. modifier QK present → 50% of the running amount
  19. modifier QX present → 50% of the running amount
  20. cap each charge and the account total at 100% of billed charges
Deer Creek - Aetna Facility Fees3 base · 21 adj
Aetna
Facility · DEER_CREEK · 2023-01-01 → 2025-11-30
Base terms — first match wins
  1. flat $0 — when NoncoverageStatus Noncovered is present
  2. 100% of billed charges — when ProcedureCode V2785 is present
  3. 100% of the Deer-Creek-Aetna-Grouper-Rate fee schedule
Adjustments — all apply, in order
  1. Medicare multiple-endoscopy reduction
  2. Medicare multiple-ophthalmology reduction — base codes 7; pays 100/80%
  3. Medicare multiple-radiology reduction — base codes 4
  4. Medicare multiple-procedure reduction — base codes 2, 3; pays 100/50/25% — when Modifier 55 is absent
  5. Medicare bilateral-surgery adjustment
  6. mid-level provider reduction (by NUCC taxonomy)
  7. modifier 22 present → 135% of the running amount
  8. modifier 52 present → 50% of the running amount
  9. custom SQL — Same global-surgery post-op allocation as hash c5fd5754fcf4a52d (Allowed/GlobalDays*PostOpRate), but hardened: falls back to returning {Allowed} unchanged when GLOB_DAYS or POST_OP is missing/non-numeric/zero instead of dividing by zero. — when Modifier 55 is present
  10. modifier 54 present → 80% of the running amount
  11. modifier 62 present → 62.5% of the running amount
  12. modifier 73 present → 50% of the running amount
  13. modifier 78 present → 70% of the running amount
  14. modifier 80 present → 16% of the running amount
  15. modifier 81 present → 16% of the running amount
  16. modifier 82 present → 16% of the running amount
  17. modifier AS present → 14% of the running amount
  18. modifier QY present → 50% of the running amount
  19. modifier QK present → 50% of the running amount
  20. modifier QX present → 50% of the running amount
  21. cap each charge and the account total at 100% of billed charges
Deer Creek - Aetna Facility Fees 20257 base · 21 adj
Aetna
Facility · DEER_CREEK · 2025-12-01 → 2999-12-31
Base terms — first match wins
  1. flat $0 — when NoncoverageStatus Noncovered is present
  2. flat $0 — when CodeRange in C9758–C9758; CodeRange in C9760–C9760; CodeRange in G0448–G0448; CodeRange in 93563–93568; CodeRange in 0408T–0415T; CodeRange in 0543T–0545T; CodeRange in 0569T–0570T; CodeRange in 0613T–0632T; CodeRange in 0643T–0646T; CodeRange in 33017–33019; CodeRange in 33289–33289; CodeRange in 33340–33340; CodeRange in 33477–33477; CodeRange in 33745–33746; CodeRange in 34717–34718; CodeRange in 93451–93462; CodeRange in 93503–93505; CodeRange in 93530–93533; CodeRange in 93590–93592; CodeRange in 93563–93568
  3. flat $0 — when CodeRange in A4641–A4642; CodeRange in A9500–A9615; CodeRange in A9698–A9698; CodeRange in A9800–A9800; CodeRange in C9067–C9067; CodeRange in Q9951–Q9969; CodeRange in Q9982–Q9983
  4. 55% of billed charges — when RevenueCode 278 is present
  5. 100% of billed charges — when ProcedureCode V2785 is present
  6. 100% of the Deer-Creek-Aetna-Carveout fee schedule
  7. 100% of the Deer-Creek-Aetna-Grouper-Rate-2025 fee schedule
Adjustments — all apply, in order
  1. Medicare multiple-endoscopy reduction
  2. Medicare multiple-ophthalmology reduction — base codes 7; pays 100/80%
  3. Medicare multiple-radiology reduction — base codes 4
  4. Medicare multiple-procedure reduction — base codes 2, 3; pays 100/50/25% — when Modifier 55 is absent
  5. Medicare bilateral-surgery adjustment
  6. mid-level provider reduction (by NUCC taxonomy)
  7. modifier 22 present → 135% of the running amount
  8. modifier 52 present → 50% of the running amount
  9. custom SQL — Same global-surgery post-op allocation as hash c5fd5754fcf4a52d (Allowed/GlobalDays*PostOpRate), but hardened: falls back to returning {Allowed} unchanged when GLOB_DAYS or POST_OP is missing/non-numeric/zero instead of dividing by zero. — when Modifier 55 is present
  10. modifier 54 present → 80% of the running amount
  11. modifier 62 present → 62.5% of the running amount
  12. modifier 73 present → 50% of the running amount
  13. modifier 78 present → 70% of the running amount
  14. modifier 80 present → 16% of the running amount
  15. modifier 81 present → 16% of the running amount
  16. modifier 82 present → 16% of the running amount
  17. modifier AS present → 14% of the running amount
  18. modifier QY present → 50% of the running amount
  19. modifier QK present → 50% of the running amount
  20. modifier QX present → 50% of the running amount
  21. cap each charge and the account total at 100% of billed charges
Deer Creek - Aetna Medicare Facility Fees3 base · 22 adj
Aetna Medicare
Facility · DEER_CREEK · 2025-12-01 → 2999-12-31
Base terms — first match wins
  1. flat $0 — when NoncoverageStatus Noncovered is present
  2. 100% of Medicare ASC
  3. 50% of billed charges
Adjustments — all apply, in order
  1. multiple-surgery reduction (contract rules) — pays 100/50/25%
  2. Medicare multiple-procedure reduction — base codes 2; pays 100/50/25%
  3. Medicare multiple-ophthalmology reduction — base codes 7; pays 100/80%
  4. Medicare multiple-endoscopy reduction
  5. Medicare multiple-radiology reduction — base codes 4
  6. Medicare bilateral-surgery adjustment
  7. mid-level provider reduction (by NUCC taxonomy)
  8. modifier 22 present → 135% of the running amount
  9. modifier 52 present → 50% of the running amount
  10. custom SQL — Same global-surgery post-op allocation as hash c5fd5754fcf4a52d (Allowed/GlobalDays*PostOpRate), but hardened: falls back to returning {Allowed} unchanged when GLOB_DAYS or POST_OP is missing/non-numeric/zero instead of dividing by zero. — when Modifier 55 is present
  11. modifier 54 present → 80% of the running amount
  12. modifier 62 present → 62.5% of the running amount
  13. modifier 73 present → 50% of the running amount
  14. modifier 78 present → 70% of the running amount
  15. modifier 80 present → 16% of the running amount
  16. modifier 81 present → 16% of the running amount
  17. modifier 82 present → 16% of the running amount
  18. modifier AS present → 14% of the running amount
  19. modifier QY present → 50% of the running amount
  20. modifier QK present → 50% of the running amount
  21. modifier QX present → 50% of the running amount
  22. cap each charge and the account total at 100% of billed charges
DeerCreek-UHC Facility Fees2 base · 21 adj
United Healthcare
Facility · DEER_CREEK · 2024-01-01 → 2999-12-31
Base terms — first match wins
  1. flat $0 — when NoncoverageStatus Noncovered is present
  2. 100% of the DeerCreek-UHC-Facility-Fees fee schedule
Adjustments — all apply, in order
  1. Medicare multiple-procedure reduction — base codes 2, 3; pays 100/50/0% — when Modifier 55 is absent
  2. Medicare multiple-endoscopy reduction
  3. Medicare multiple-radiology reduction — base codes 4
  4. Medicare bilateral-surgery adjustment
  5. mid-level provider reduction (by NUCC taxonomy)
  6. modifier 22 present → 135% of the running amount
  7. modifier 53 present → 25% of the running amount
  8. modifier 52 present → 50% of the running amount
  9. custom SQL — Same global-surgery post-op allocation as hash c5fd5754fcf4a52d (Allowed/GlobalDays*PostOpRate), but hardened: falls back to returning {Allowed} unchanged when GLOB_DAYS or POST_OP is missing/non-numeric/zero instead of dividing by zero. — when Modifier 55 is present
  10. modifier 54 present → 80% of the running amount
  11. modifier 62 present → 62.5% of the running amount
  12. modifier 73 present → 50% of the running amount
  13. modifier 78 present → 70% of the running amount
  14. modifier 80 present → 16% of the running amount
  15. modifier 81 present → 16% of the running amount
  16. modifier 82 present → 16% of the running amount
  17. modifier AS present → 14% of the running amount
  18. modifier QY present → 50% of the running amount
  19. modifier QK present → 50% of the running amount
  20. modifier QX present → 50% of the running amount
  21. cap each charge and the account total at 100% of billed charges
ESC Elizabethtown - Humana Facility Fees7 base · 21 adj
Humana
Facility · KENYON_ASC_NEXTGEN · 2021-10-01 → 2024-07-31
Base terms — first match wins
  1. flat $0 — when NoncoverageStatus Noncovered is present
  2. flat $6000 — when ProcedureCode 65730 is present
  3. flat $6000 — when ProcedureCode 65750 is present
  4. flat $6000 — when ProcedureCode 65755 is present
  5. flat $6000 — when ProcedureCode 65756 is present
  6. 120% of Medicare ASC
  7. flat $0
Adjustments — all apply, in order
  1. multiple-surgery reduction (contract rules) — pays 100/50%
  2. Medicare multiple-procedure reduction — base codes 2; pays 100/50%
  3. Medicare multiple-endoscopy reduction
  4. Medicare multiple-radiology reduction — base codes 4
  5. Medicare bilateral-surgery adjustment
  6. mid-level provider reduction (by NUCC taxonomy)
  7. modifier 22 present → 135% of the running amount
  8. modifier 52 present → 50% of the running amount
  9. custom SQL — Same global-surgery post-op allocation as hash c5fd5754fcf4a52d (Allowed/GlobalDays*PostOpRate), but hardened: falls back to returning {Allowed} unchanged when GLOB_DAYS or POST_OP is missing/non-numeric/zero instead of dividing by zero. — when Modifier 55 is present
  10. modifier 54 present → 80% of the running amount
  11. modifier 62 present → 62.5% of the running amount
  12. modifier 73 present → 50% of the running amount
  13. modifier 78 present → 70% of the running amount
  14. modifier 80 present → 16% of the running amount
  15. modifier 81 present → 16% of the running amount
  16. modifier 82 present → 16% of the running amount
  17. modifier AS present → 14% of the running amount
  18. modifier QY present → 50% of the running amount
  19. modifier QK present → 50% of the running amount
  20. modifier QX present → 50% of the running amount
  21. cap each charge and the account total at 100% of billed charges
ElizabethTown-Anthem Commercial Facility Fees3 base · 21 adj
Anthem Commercial Plans, Anthem HMO, Anthem PPO
Facility · 2 named facilities · 2023-01-01 → 2999-12-31
Base terms — first match wins
  1. flat $0 — when NoncoverageStatus Noncovered is present
  2. case rate from CaseRate (All-level codes)
  3. 45% of billed charges
Adjustments — all apply, in order
  1. Medicare multiple-procedure reduction — base codes 2, 3; pays 100/50% — when Modifier 55 is absent
  2. Medicare multiple-ophthalmology reduction — base codes 7; pays 100/80%
  3. Medicare multiple-endoscopy reduction
  4. Medicare multiple-radiology reduction — base codes 4
  5. Medicare bilateral-surgery adjustment
  6. mid-level provider reduction (by NUCC taxonomy)
  7. modifier 22 present → 135% of the running amount
  8. modifier 52 present → 50% of the running amount
  9. custom SQL — Same global-surgery post-op allocation as hash c5fd5754fcf4a52d (Allowed/GlobalDays*PostOpRate), but hardened: falls back to returning {Allowed} unchanged when GLOB_DAYS or POST_OP is missing/non-numeric/zero instead of dividing by zero. — when Modifier 55 is present
  10. modifier 54 present → 80% of the running amount
  11. modifier 62 present → 62.5% of the running amount
  12. modifier 73 present → 50% of the running amount
  13. modifier 78 present → 70% of the running amount
  14. modifier 80 present → 16% of the running amount
  15. modifier 81 present → 16% of the running amount
  16. modifier 82 present → 16% of the running amount
  17. modifier AS present → 14% of the running amount
  18. modifier QY present → 50% of the running amount
  19. modifier QK present → 50% of the running amount
  20. modifier QX present → 50% of the running amount
  21. cap each charge and the account total at 100% of billed charges
Humana3 base · 20 adj
Humana
Profee · SABATES_EYE, ASC, Clinic, Home, Hospital · 2008-12-01 → 2999-12-31
Base terms — first match wins
  1. flat $0 — when NoncoverageStatus Noncovered is present
  2. 100% of Medicare drug
  3. 100% of the Profee-Fees fee schedule
Adjustments — all apply, in order
  1. Medicare multiple-procedure reduction — base codes 2, 3; pays 100/50% — when Modifier 55 is absent; Modifier 82 is absent
  2. Medicare multiple-endoscopy reduction
  3. Medicare multiple-radiology reduction — base codes 4
  4. Medicare bilateral-surgery adjustment
  5. mid-level provider reduction (by NUCC taxonomy)
  6. modifier 22 present → 135% of the running amount
  7. modifier 52 present → 50% of the running amount
  8. custom SQL — Same global-surgery post-op allocation as hash c5fd5754fcf4a52d (Allowed/GlobalDays*PostOpRate), but hardened: falls back to returning {Allowed} unchanged when GLOB_DAYS or POST_OP is missing/non-numeric/zero instead of dividing by zero. — when Modifier 55 is present
  9. modifier 54 present → 80% of the running amount
  10. modifier 62 present → 62.5% of the running amount
  11. modifier 73 present → 50% of the running amount
  12. modifier 78 present → 70% of the running amount
  13. modifier 80 present → 16% of the running amount
  14. modifier 81 present → 16% of the running amount
  15. modifier 82 present → 16% of the running amount
  16. modifier AS present → 14% of the running amount
  17. modifier QY present → 50% of the running amount
  18. modifier QK present → 50% of the running amount
  19. modifier QX present → 50% of the running amount
  20. cap each charge and the account total at 100% of billed charges
Humana McPeak3 base · 20 adj
Humana
Profee · MCPEAK · 2023-01-01 → 2024-04-30
Base terms — first match wins
  1. flat $0 — when NoncoverageStatus Noncovered is present
  2. 100% of the Profee-Drug fee schedule
  3. 100% of the Humana-Profee-Fees fee schedule
Adjustments — all apply, in order
  1. Medicare multiple-procedure reduction — base codes 2, 3; pays 100/50% — when Modifier 55 is absent; Modifier 82 is absent
  2. Medicare multiple-endoscopy reduction
  3. Medicare multiple-radiology reduction — base codes 4
  4. Medicare bilateral-surgery adjustment
  5. mid-level provider reduction (by NUCC taxonomy)
  6. modifier 22 present → 135% of the running amount
  7. modifier 52 present → 50% of the running amount
  8. custom SQL — Same global-surgery post-op allocation as hash c5fd5754fcf4a52d (Allowed/GlobalDays*PostOpRate), but hardened: falls back to returning {Allowed} unchanged when GLOB_DAYS or POST_OP is missing/non-numeric/zero instead of dividing by zero. — when Modifier 55 is present
  9. modifier 54 present → 80% of the running amount
  10. modifier 62 present → 62.5% of the running amount
  11. modifier 73 present → 50% of the running amount
  12. modifier 78 present → 70% of the running amount
  13. modifier 80 present → 16% of the running amount
  14. modifier 81 present → 16% of the running amount
  15. modifier 82 present → 16% of the running amount
  16. modifier AS present → 14% of the running amount
  17. modifier QY present → 50% of the running amount
  18. modifier QK present → 50% of the running amount
  19. modifier QX present → 50% of the running amount
  20. cap each charge and the account total at 100% of billed charges
Humana Medicare McPeak3 base · 20 adj
Humana Medicare
Profee · MCPEAK · 2023-01-01 → 2999-12-31
Base terms — first match wins
  1. flat $0 — when NoncoverageStatus Noncovered is present
  2. 100% of the Profee-Drug fee schedule
  3. 100% of the Humana-Profee-Fees fee schedule
Adjustments — all apply, in order
  1. Medicare multiple-procedure reduction — base codes 2, 3; pays 100/50% — when Modifier 55 is absent; Modifier 82 is absent
  2. Medicare multiple-endoscopy reduction
  3. Medicare multiple-radiology reduction — base codes 4
  4. Medicare bilateral-surgery adjustment
  5. mid-level provider reduction (by NUCC taxonomy)
  6. modifier 22 present → 135% of the running amount
  7. modifier 52 present → 50% of the running amount
  8. custom SQL — Same global-surgery post-op allocation as hash c5fd5754fcf4a52d (Allowed/GlobalDays*PostOpRate), but hardened: falls back to returning {Allowed} unchanged when GLOB_DAYS or POST_OP is missing/non-numeric/zero instead of dividing by zero. — when Modifier 55 is present
  9. modifier 54 present → 80% of the running amount
  10. modifier 62 present → 62.5% of the running amount
  11. modifier 73 present → 50% of the running amount
  12. modifier 78 present → 70% of the running amount
  13. modifier 80 present → 16% of the running amount
  14. modifier 81 present → 16% of the running amount
  15. modifier 82 present → 16% of the running amount
  16. modifier AS present → 14% of the running amount
  17. modifier QY present → 50% of the running amount
  18. modifier QK present → 50% of the running amount
  19. modifier QX present → 50% of the running amount
  20. cap each charge and the account total at 100% of billed charges
Humana-Medicare3 base · 20 adj
Humana Medicare
Profee · SABATES_EYE, Clinic · 2008-10-01 → 2999-12-31
Humana Medicare
Profee · SABATES_EYE, ASC, Hospital · 2008-10-01 → 2999-12-31
Base terms — first match wins
  1. flat $0 — when NoncoverageStatus Noncovered is present
  2. 100% of Medicare drug
  3. 100% of the Profee-Fees fee schedule
Adjustments — all apply, in order
  1. Medicare multiple-procedure reduction — base codes 2, 3; pays 100/50% — when Modifier 55 is absent; Modifier 82 is absent
  2. Medicare multiple-endoscopy reduction
  3. Medicare multiple-radiology reduction — base codes 4
  4. Medicare bilateral-surgery adjustment
  5. mid-level provider reduction (by NUCC taxonomy)
  6. modifier 22 present → 135% of the running amount
  7. modifier 52 present → 50% of the running amount
  8. custom SQL — Same global-surgery post-op allocation as hash c5fd5754fcf4a52d (Allowed/GlobalDays*PostOpRate), but hardened: falls back to returning {Allowed} unchanged when GLOB_DAYS or POST_OP is missing/non-numeric/zero instead of dividing by zero. — when Modifier 55 is present
  9. modifier 54 present → 80% of the running amount
  10. modifier 62 present → 62.5% of the running amount
  11. modifier 73 present → 50% of the running amount
  12. modifier 78 present → 70% of the running amount
  13. modifier 80 present → 16% of the running amount
  14. modifier 81 present → 16% of the running amount
  15. modifier 82 present → 16% of the running amount
  16. modifier AS present → 14% of the running amount
  17. modifier QY present → 50% of the running amount
  18. modifier QK present → 50% of the running amount
  19. modifier QX present → 50% of the running amount
  20. cap each charge and the account total at 100% of billed charges
Humana-Medicare-RAK5 base · 20 adj
Humana Medicare
Profee · RAK · 2023-01-01 → 2024-04-30
Base terms — first match wins
  1. flat $0 — when NoncoverageStatus Noncovered is present
  2. 50% of Medicare lab
  3. 100% of Medicare drug
  4. 95% of Medicare DME
  5. 95% of Medicare RVU
Adjustments — all apply, in order
  1. Medicare multiple-procedure reduction — base codes 2, 3; pays 100/50% — when Modifier 55 is absent; Modifier 82 is absent
  2. Medicare multiple-endoscopy reduction
  3. Medicare multiple-radiology reduction — base codes 4
  4. Medicare bilateral-surgery adjustment
  5. mid-level provider reduction (by NUCC taxonomy)
  6. modifier 22 present → 135% of the running amount
  7. modifier 52 present → 50% of the running amount
  8. custom SQL — Same global-surgery post-op allocation as hash c5fd5754fcf4a52d (Allowed/GlobalDays*PostOpRate), but hardened: falls back to returning {Allowed} unchanged when GLOB_DAYS or POST_OP is missing/non-numeric/zero instead of dividing by zero. — when Modifier 55 is present
  9. modifier 54 present → 80% of the running amount
  10. modifier 62 present → 62.5% of the running amount
  11. modifier 73 present → 50% of the running amount
  12. modifier 78 present → 70% of the running amount
  13. modifier 80 present → 16% of the running amount
  14. modifier 81 present → 16% of the running amount
  15. modifier 82 present → 16% of the running amount
  16. modifier AS present → 14% of the running amount
  17. modifier QY present → 50% of the running amount
  18. modifier QK present → 50% of the running amount
  19. modifier QX present → 50% of the running amount
  20. cap each charge and the account total at 100% of billed charges
IN Medicaid Profees5 base · 20 adj
IN Anthem Medicaid
Profee · CVP_MIDWEST, NOVUS, RS_OHIO · 2023-01-01 → 2999-12-31
IN Anthem Medicaid
Profee · KENYON_ASC_NEXTGEN, KENYON_NEXTGEN · 2023-01-01 → 2999-12-31
Base terms — first match wins
  1. flat $0 — when NoncoverageStatus Noncovered is present
  2. percent-of-charges, rate read from the Percent of Charges schedule
  3. 100% of the Fixed-Fees fee schedule
  4. 100% of the Profee-Fees fee schedule
  5. 0% of billed charges
Adjustments — all apply, in order
  1. Medicare multiple-procedure reduction — base codes 2, 3; pays 100/50% — when Modifier 55 is absent; Modifier 82 is absent
  2. Medicare multiple-endoscopy reduction
  3. Medicare multiple-radiology reduction — base codes 4
  4. Medicare bilateral-surgery adjustment
  5. mid-level provider reduction (by NUCC taxonomy)
  6. modifier 22 present → 135% of the running amount
  7. modifier 52 present → 50% of the running amount
  8. custom SQL — Same global-surgery post-op allocation as hash c5fd5754fcf4a52d (Allowed/GlobalDays*PostOpRate), but hardened: falls back to returning {Allowed} unchanged when GLOB_DAYS or POST_OP is missing/non-numeric/zero instead of dividing by zero. — when Modifier 55 is present
  9. modifier 54 present → 80% of the running amount
  10. modifier 62 present → 62.5% of the running amount
  11. modifier 73 present → 50% of the running amount
  12. modifier 78 present → 70% of the running amount
  13. modifier 80 present → 16% of the running amount
  14. modifier 81 present → 16% of the running amount
  15. modifier 82 present → 16% of the running amount
  16. modifier AS present → 14% of the running amount
  17. modifier QY present → 50% of the running amount
  18. modifier QK present → 50% of the running amount
  19. modifier QX present → 50% of the running amount
  20. cap each charge and the account total at 100% of billed charges
JohnKenyon - Humana Medicare Profees3 base · 20 adj
Humana Medicare
Profee · KENYON_ASC_NEXTGEN, KENYON_NEXTGEN · 2023-01-01 → 2999-12-31
Base terms — first match wins
  1. flat $0 — when NoncoverageStatus Noncovered is present
  2. 100% of the Profee-Fees fee schedule
  3. 100% of the Fixed-Fees-Drugs fee schedule
Adjustments — all apply, in order
  1. Medicare multiple-procedure reduction — base codes 2, 3; pays 100/50% — when Modifier 55 is absent; Modifier 82 is absent
  2. Medicare multiple-endoscopy reduction
  3. Medicare multiple-radiology reduction — base codes 4
  4. Medicare bilateral-surgery adjustment
  5. mid-level provider reduction (by NUCC taxonomy)
  6. modifier 22 present → 135% of the running amount
  7. modifier 52 present → 50% of the running amount
  8. custom SQL — Same global-surgery post-op allocation as hash c5fd5754fcf4a52d (Allowed/GlobalDays*PostOpRate), but hardened: falls back to returning {Allowed} unchanged when GLOB_DAYS or POST_OP is missing/non-numeric/zero instead of dividing by zero. — when Modifier 55 is present
  9. modifier 54 present → 80% of the running amount
  10. modifier 62 present → 62.5% of the running amount
  11. modifier 73 present → 50% of the running amount
  12. modifier 78 present → 70% of the running amount
  13. modifier 80 present → 16% of the running amount
  14. modifier 81 present → 16% of the running amount
  15. modifier 82 present → 16% of the running amount
  16. modifier AS present → 14% of the running amount
  17. modifier QY present → 50% of the running amount
  18. modifier QK present → 50% of the running amount
  19. modifier QX present → 50% of the running amount
  20. cap each charge and the account total at 100% of billed charges
KY Medicaid - Profees4 base · 20 adj
Anthem Medicaid KY
Profee · KENYON_ASC_NEXTGEN, KENYON_NEXTGEN · 2023-01-01 → 2999-12-31
United Healthcare Medicaid
Profee · KENYON_ASC_NEXTGEN, KENYON_NEXTGEN · 2023-01-01 → 2999-12-31
Anthem Medicaid, Anthem Medicaid KY
Profee · PADUCAH · 2023-01-01 → 2999-12-31
United Healthcare Medicaid
Profee · PADUCAH · 2023-01-01 → 2999-12-31
Base terms — first match wins
  1. 45% of billed charges — when KYMedicaidBCCode True is present
  2. 100% of the Fixed-Fees-Labs fee schedule
  3. 100% of the KY-Medicaid-Profee-Fees fee schedule — when FacilityType in Clinic
  4. 100% of the KY-Medicaid-Facility-Profee-Fees fee schedule
Adjustments — all apply, in order
  1. Medicare multiple-procedure reduction — base codes 2, 3; pays 100/50% — when Modifier 55 is absent; Modifier 82 is absent
  2. Medicare multiple-endoscopy reduction
  3. Medicare multiple-radiology reduction — base codes 4
  4. mid-level provider reduction (by NUCC taxonomy)
  5. modifier 22 present → 135% of the running amount
  6. modifier 50 present → 150% of the running amount
  7. modifier 52 present → 50% of the running amount
  8. custom SQL — Same global-surgery post-op allocation as hash c5fd5754fcf4a52d (Allowed/GlobalDays*PostOpRate), but hardened: falls back to returning {Allowed} unchanged when GLOB_DAYS or POST_OP is missing/non-numeric/zero instead of dividing by zero. — when Modifier 55 is present
  9. modifier 54 present → 80% of the running amount
  10. modifier 62 present → 62.5% of the running amount
  11. modifier 73 present → 50% of the running amount
  12. modifier 78 present → 70% of the running amount
  13. modifier 80 present → 16% of the running amount
  14. modifier 81 present → 16% of the running amount
  15. modifier 82 present → 16% of the running amount
  16. modifier AS present → 14% of the running amount
  17. modifier QY present → 50% of the running amount
  18. modifier QK present → 50% of the running amount
  19. modifier QX present → 50% of the running amount
  20. cap each charge and the account total at 100% of billed charges
Largo ASC - UHC Medicare Facility Fees7 base · 22 adj
United Healthcare Medicare
Facility · LargoASC · 2023-01-01 → 2999-12-31
Base terms — first match wins
  1. flat $0 — when NoncoverageStatus Noncovered is present
  2. flat $2900 — when ProcedureCode V2785 is present
  3. flat $6100 — when ProcedureCode C1821 is present
  4. flat $8450 — when ProcedureCode C1821 is present
  5. percent-of-charges, rate read from the Percent of Charges schedule
  6. 100% of Medicare ASC
  7. flat $0
Adjustments — all apply, in order
  1. multiple-surgery reduction (contract rules) — pays 100/50%
  2. Medicare multiple-procedure reduction — base codes 2; pays 100/50/25/0%
  3. Medicare multiple-endoscopy reduction
  4. Medicare multiple-radiology reduction — base codes 4
  5. Medicare bilateral-surgery adjustment
  6. mid-level provider reduction (by NUCC taxonomy)
  7. modifier 22 present → 135% of the running amount
  8. modifier 52 present → 50% of the running amount
  9. modifier 53 present → 25% of the running amount
  10. custom SQL — Same global-surgery post-op allocation as hash c5fd5754fcf4a52d (Allowed/GlobalDays*PostOpRate), but hardened: falls back to returning {Allowed} unchanged when GLOB_DAYS or POST_OP is missing/non-numeric/zero instead of dividing by zero. — when Modifier 55 is present
  11. modifier 54 present → 80% of the running amount
  12. modifier 62 present → 62.5% of the running amount
  13. modifier 73 present → 50% of the running amount
  14. modifier 78 present → 70% of the running amount
  15. modifier 80 present → 16% of the running amount
  16. modifier 81 present → 16% of the running amount
  17. modifier 82 present → 16% of the running amount
  18. modifier AS present → 14% of the running amount
  19. modifier QY present → 50% of the running amount
  20. modifier QK present → 50% of the running amount
  21. modifier QX present → 50% of the running amount
  22. cap each charge and the account total at 100% of billed charges
McPeak Anthem ASC4 base · 21 adj
Anthem Commercial Plans
Facility · MCPEAK, ASC, Hospital · 2024-01-01 → 2024-12-31
Base terms — first match wins
  1. flat $0 — when NoncoverageStatus Noncovered is present
  2. 100% of the Facility-Fees fee schedule
  3. 100% of the Carveouts fee schedule
  4. 60% of billed charges
Adjustments — all apply, in order
  1. Medicare multiple-procedure reduction — base codes 2, 3; pays 100/50% — when Modifier 55 is absent
  2. Medicare multiple-ophthalmology reduction — base codes 7; pays 100/80%
  3. Medicare multiple-endoscopy reduction
  4. Medicare multiple-radiology reduction — base codes 4
  5. Medicare bilateral-surgery adjustment
  6. mid-level provider reduction (by NUCC taxonomy)
  7. modifier 22 present → 135% of the running amount
  8. modifier 52 present → 50% of the running amount
  9. custom SQL — Same global-surgery post-op allocation as hash c5fd5754fcf4a52d (Allowed/GlobalDays*PostOpRate), but hardened: falls back to returning {Allowed} unchanged when GLOB_DAYS or POST_OP is missing/non-numeric/zero instead of dividing by zero. — when Modifier 55 is present
  10. modifier 54 present → 80% of the running amount
  11. modifier 62 present → 62.5% of the running amount
  12. modifier 73 present → 50% of the running amount
  13. modifier 78 present → 70% of the running amount
  14. modifier 80 present → 16% of the running amount
  15. modifier 81 present → 16% of the running amount
  16. modifier 82 present → 16% of the running amount
  17. modifier AS present → 14% of the running amount
  18. modifier QY present → 50% of the running amount
  19. modifier QK present → 50% of the running amount
  20. modifier QX present → 50% of the running amount
  21. cap each charge and the account total at 100% of billed charges
McPeak Anthem ASC 20255 base · 21 adj
Anthem Commercial Plans
Facility · MCPEAK, ASC, Hospital · 2025-01-01 → 2999-12-31
Base terms — first match wins
  1. flat $0 — when NoncoverageStatus Noncovered is present
  2. 100% of billed charges — when ProcedureCode V2785 is present
  3. 100% of the Facility-Fees fee schedule
  4. 100% of the Carveouts fee schedule
  5. 45% of billed charges
Adjustments — all apply, in order
  1. Medicare multiple-procedure reduction — base codes 2, 3; pays 100/50% — when Modifier 55 is absent
  2. Medicare multiple-ophthalmology reduction — base codes 7; pays 100/80%
  3. Medicare multiple-endoscopy reduction
  4. Medicare multiple-radiology reduction — base codes 4
  5. Medicare bilateral-surgery adjustment
  6. mid-level provider reduction (by NUCC taxonomy)
  7. modifier 22 present → 135% of the running amount
  8. modifier 52 present → 50% of the running amount
  9. custom SQL — Same global-surgery post-op allocation as hash c5fd5754fcf4a52d (Allowed/GlobalDays*PostOpRate), but hardened: falls back to returning {Allowed} unchanged when GLOB_DAYS or POST_OP is missing/non-numeric/zero instead of dividing by zero. — when Modifier 55 is present
  10. modifier 54 present → 80% of the running amount
  11. modifier 62 present → 62.5% of the running amount
  12. modifier 73 present → 50% of the running amount
  13. modifier 78 present → 70% of the running amount
  14. modifier 80 present → 16% of the running amount
  15. modifier 81 present → 16% of the running amount
  16. modifier 82 present → 16% of the running amount
  17. modifier AS present → 14% of the running amount
  18. modifier QY present → 50% of the running amount
  19. modifier QK present → 50% of the running amount
  20. modifier QX present → 50% of the running amount
  21. cap each charge and the account total at 100% of billed charges
McPeak-Anthem-Profee4 base · 21 adj
Anthem HMO
Profee · MCPEAK · 2022-06-17 → 2999-12-31
Anthem PPO
Profee · MCPEAK · 2022-06-17 → 2999-12-31
Anthem Commercial Plans
Profee · MCPEAK · 2024-11-01 → 2999-12-31
Base terms — first match wins
  1. flat $0 — when NoncoverageStatus Noncovered is present
  2. 100% of the Carveouts fee schedule
  3. 100% of Medicare drug
  4. 100% of the Profee-Fees fee schedule
Adjustments — all apply, in order
  1. Medicare multiple-procedure reduction — base codes 2, 3; pays 100/50% — when Modifier 55 is absent; Modifier 82 is absent
  2. Medicare multiple-ophthalmology reduction — base codes 7; pays 100/80%
  3. Medicare multiple-endoscopy reduction
  4. Medicare multiple-radiology reduction — base codes 4
  5. Medicare bilateral-surgery adjustment
  6. mid-level provider reduction (by NUCC taxonomy)
  7. modifier 22 present → 135% of the running amount
  8. modifier 52 present → 50% of the running amount
  9. custom SQL — Same global-surgery post-op allocation as hash c5fd5754fcf4a52d (Allowed/GlobalDays*PostOpRate), but hardened: falls back to returning {Allowed} unchanged when GLOB_DAYS or POST_OP is missing/non-numeric/zero instead of dividing by zero. — when Modifier 55 is present
  10. modifier 54 present → 80% of the running amount
  11. modifier 62 present → 62.5% of the running amount
  12. modifier 73 present → 50% of the running amount
  13. modifier 78 present → 70% of the running amount
  14. modifier 80 present → 16% of the running amount
  15. modifier 81 present → 16% of the running amount
  16. modifier 82 present → 16% of the running amount
  17. modifier AS present → 14% of the running amount
  18. modifier QY present → 50% of the running amount
  19. modifier QK present → 50% of the running amount
  20. modifier QX present → 50% of the running amount
  21. cap each charge and the account total at 100% of billed charges
Medica4 base · 20 adj
Medica
Profee · SABATES_EYE · 2023-04-01 → 2999-12-31
Base terms — first match wins
  1. flat $0 — when NoncoverageStatus Noncovered is present
  2. 100% of Medicare drug
  3. 100% of the Profee-Fees fee schedule
  4. 50% of billed charges
Adjustments — all apply, in order
  1. Medicare multiple-procedure reduction — base codes 2, 3; pays 100/50% — when Modifier 55 is absent; Modifier 82 is absent
  2. Medicare multiple-endoscopy reduction
  3. Medicare multiple-radiology reduction — base codes 4
  4. Medicare bilateral-surgery adjustment
  5. mid-level provider reduction (by NUCC taxonomy)
  6. modifier 22 present → 135% of the running amount
  7. modifier 52 present → 50% of the running amount
  8. custom SQL — Same global-surgery post-op allocation as hash c5fd5754fcf4a52d (Allowed/GlobalDays*PostOpRate), but hardened: falls back to returning {Allowed} unchanged when GLOB_DAYS or POST_OP is missing/non-numeric/zero instead of dividing by zero. — when Modifier 55 is present
  9. modifier 54 present → 80% of the running amount
  10. modifier 62 present → 62.5% of the running amount
  11. modifier 73 present → 50% of the running amount
  12. modifier 78 present → 70% of the running amount
  13. modifier 80 present → 16% of the running amount
  14. modifier 81 present → 16% of the running amount
  15. modifier 82 present → 16% of the running amount
  16. modifier AS present → 14% of the running amount
  17. modifier QY present → 50% of the running amount
  18. modifier QK present → 50% of the running amount
  19. modifier QX present → 50% of the running amount
  20. cap each charge and the account total at 100% of billed charges
Medica-Medicare4 base · 20 adj
Medica Medicare
Profee · SABATES_EYE · 2023-01-01 → 2999-12-31
Base terms — first match wins
  1. flat $0 — when NoncoverageStatus Noncovered is present
  2. 100% of Medicare drug
  3. 100% of the Profee-Fees fee schedule
  4. 45% of billed charges
Adjustments — all apply, in order
  1. Medicare multiple-procedure reduction — base codes 2, 3; pays 100/50% — when Modifier 55 is absent; Modifier 82 is absent
  2. Medicare multiple-endoscopy reduction
  3. Medicare multiple-radiology reduction — base codes 4
  4. Medicare bilateral-surgery adjustment
  5. mid-level provider reduction (by NUCC taxonomy)
  6. modifier 22 present → 135% of the running amount
  7. modifier 52 present → 50% of the running amount
  8. custom SQL — Same global-surgery post-op allocation as hash c5fd5754fcf4a52d (Allowed/GlobalDays*PostOpRate), but hardened: falls back to returning {Allowed} unchanged when GLOB_DAYS or POST_OP is missing/non-numeric/zero instead of dividing by zero. — when Modifier 55 is present
  9. modifier 54 present → 80% of the running amount
  10. modifier 62 present → 62.5% of the running amount
  11. modifier 73 present → 50% of the running amount
  12. modifier 78 present → 70% of the running amount
  13. modifier 80 present → 16% of the running amount
  14. modifier 81 present → 16% of the running amount
  15. modifier 82 present → 16% of the running amount
  16. modifier AS present → 14% of the running amount
  17. modifier QY present → 50% of the running amount
  18. modifier QK present → 50% of the running amount
  19. modifier QX present → 50% of the running amount
  20. cap each charge and the account total at 100% of billed charges
Medicaid2 base · 20 adj
Sentara Medicaid
Facility · CVP_MIDATLANTIC · 2021-01-01 → 2999-12-31
Aetna BetterHealth Medicaid
Facility · CVP_MIDATLANTIC · 2021-01-01 → 2999-12-31
Aetna Medicaid
Facility · CVP_MIDATLANTIC · 2023-01-01 → 2999-12-31
Base terms — first match wins
  1. flat $0 — when NoncoverageStatus Noncovered is present
  2. 100% of the Profee-Fees fee schedule
Adjustments — all apply, in order
  1. Medicare multiple-procedure reduction — base codes 2, 3; pays 100/50% — when Modifier 55 is absent; Modifier 82 is absent
  2. Medicare multiple-endoscopy reduction
  3. Medicare multiple-radiology reduction — base codes 4
  4. Medicare bilateral-surgery adjustment
  5. mid-level provider reduction (by NUCC taxonomy)
  6. modifier 22 present → 135% of the running amount
  7. modifier 52 present → 50% of the running amount
  8. custom SQL — Same global-surgery post-op allocation as hash c5fd5754fcf4a52d (Allowed/GlobalDays*PostOpRate), but hardened: falls back to returning {Allowed} unchanged when GLOB_DAYS or POST_OP is missing/non-numeric/zero instead of dividing by zero. — when Modifier 55 is present
  9. modifier 54 present → 80% of the running amount
  10. modifier 62 present → 62.5% of the running amount
  11. modifier 73 present → 50% of the running amount
  12. modifier 78 present → 70% of the running amount
  13. modifier 80 present → 16% of the running amount
  14. modifier 81 present → 16% of the running amount
  15. modifier 82 present → 16% of the running amount
  16. modifier AS present → 14% of the running amount
  17. modifier QY present → 50% of the running amount
  18. modifier QK present → 50% of the running amount
  19. modifier QX present → 50% of the running amount
  20. cap each charge and the account total at 100% of billed charges
Medicare7 base · 20 adj
Cigna Medicare
Profee · SABATES_EYE · 2020-01-01 → 2999-12-31
BCBS KS Medicare
Profee · SABATES_EYE · 2022-10-01 → 2999-12-31
Medicare
Profee · all facilities · 2023-01-01 → 2999-12-31
HAP Medicare
Profee · ASSOCIATED_RETINAL · 2023-01-01 → 2999-12-31
McClaren Medicare
Profee · ASSOCIATED_RETINAL · 2023-01-01 → 2999-12-31
Meridian Medicare
Profee · ASSOCIATED_RETINAL · 2023-01-01 → 2999-12-31
Priority Health Medicare
Profee · ASSOCIATED_RETINAL · 2023-01-01 → 2999-12-31
Reliance Medicare
Profee · ASSOCIATED_RETINAL · 2023-01-01 → 2999-12-31
Sentara Medicare
Profee · CVP_MIDATLANTIC · 2023-01-01 → 2999-12-31
Aetna BetterHealth Medicare, Sentara Medicare
Profee · BSV_EyeClinicMichigan · 2023-01-01 → 2999-12-31
HAP Medicare
Profee · BSV_EyeClinicMichigan · 2023-01-01 → 2999-12-31
McClaren Medicare
Profee · BSV_EyeClinicMichigan · 2023-01-01 → 2999-12-31
Meridian Medicare
Profee · BSV_EyeClinicMichigan · 2023-01-01 → 2999-12-31
Molina Medicare
Profee · BSV_EyeClinicMichigan · 2023-01-01 → 2999-12-31
Priority Health Medicare
Profee · BSV_EyeClinicMichigan · 2023-01-01 → 2999-12-31
Reliance Medicare
Profee · BSV_EyeClinicMichigan · 2023-01-01 → 2999-12-31
Meridian Medicare
Profee · BSV_GRO · 2023-01-01 → 2999-12-31
HAP Medicare
Profee · HURON_OPH · 2023-01-01 → 2999-12-31
MHP Medicare
Profee · HURON_OPH · 2023-01-01 → 2999-12-31
Priority Health Medicare
Profee · BYRD_AND_WYAN · 2023-01-01 → 2999-12-31
United Healthcare Medicare
Profee · BYRD_AND_WYAN · 2023-01-01 → 2999-12-31
Cigna Medicare
Profee · EIWF · 2023-01-01 → 2999-12-31
Devoted Medicare
Profee · EIWF · 2023-01-01 → 2999-12-31
Multiplan Medicare
Profee · EIWF · 2023-01-01 → 2999-12-31
Aetna Cofinity Medicare
Profee · LargoASC · 2023-01-01 → 2999-12-31
BCBS Medicare Plans
Profee · LargoASC · 2023-01-01 → 2999-12-31
Cigna Medicare
Profee · LargoASC · 2023-01-01 → 2999-12-31
United Healthcare Medicare
Profee · LargoASC · 2023-01-01 → 2999-12-31
Cigna Medicare
Profee · Monmouth · 2023-01-01 → 2999-12-31
Priority Health Medicare
Profee · OAKLAND_OPH · 2023-01-01 → 2999-12-31
United Healthcare Medicare
Profee · OAKLAND_OPH · 2023-01-01 → 2999-12-31
BCBS Medicare Plans
Profee · SOUTHGATE · 2023-01-01 → 2999-12-31
HAP Medicare
Profee · SOUTHGATE · 2023-01-01 → 2999-12-31
Priority Health Medicare
Profee · SOUTHGATE · 2023-01-01 → 2999-12-31
BCBS Medicare Plans
Profee · StPetersburgASC · 2023-01-01 → 2999-12-31
Cigna Medicare
Profee · StPetersburgASC · 2023-01-01 → 2999-12-31
Multiplan Medicare
Profee · StPetersburgASC · 2023-01-01 → 2999-12-31
Molina Medicare
Profee · WalkerSurgeryCenter · 2023-01-01 → 2999-12-31
Frontpath Medicare
Profee · BSV_GRO, WalkerSurgeryCenter, BSV_EyeClinicMichigan, BSV, BSV_TukelEye · 2023-01-01 → 2999-12-31
HAP Medicare
Profee · BSV_GRO, WalkerSurgeryCenter, BSV, BSV_TukelEye · 2023-01-01 → 2999-12-31
Align Medicare
Profee · CVP_MIDATLANTIC · 2023-01-01 → 2999-12-31
Clear Spring Medicare
Profee · CVP_MIDATLANTIC · 2023-01-01 → 2999-12-31
Lifeworks Medicare
Profee · CVP_MIDATLANTIC · 2023-01-01 → 2999-12-31
Cigna Medicare
Profee · ARIZONA_EYE · 2023-06-01 → 2999-12-31
BCBS KS Medicare
Profee · GRENE_VISION · 2023-01-01 → 2999-12-31
Aetna BetterHealth Medicare
Profee · CVP_MIDWEST, NOVUS, RS_OHIO · 2023-01-01 → 2999-12-31
Medical Mutual Medicare
Profee · CVP_MIDWEST, NOVUS, RS_OHIO · 2023-01-01 → 2999-12-31
MediGold
Profee · CVP_MIDWEST, NOVUS, RS_OHIO · 2023-01-01 → 2999-12-31
Molina Medicare
Profee · CVP_MIDWEST, NOVUS, RS_OHIO · 2023-01-01 → 2999-12-31
OH Healthy Medicare
Profee · CVP_MIDWEST, NOVUS, RS_OHIO · 2023-01-01 → 2999-12-31
UHC VACCN
Profee · CVP_MIDWEST, NOVUS, RS_OHIO · 2023-01-01 → 2999-12-31
Cigna Medicare
Profee · CVP_MIDATLANTIC · 2023-01-01 → 2999-12-31
Molina Medicare
Profee · CVP_MIDATLANTIC · 2023-01-01 → 2999-12-31
UHC VACCN
Profee · CVP_MIDATLANTIC · 2023-01-01 → 2999-12-31
Devoted Medicare
Profee · AVC_ALABAMA · 2023-01-01 → 2999-12-31
UHC VACCN
Profee · AVC_ALABAMA · 2023-01-01 → 2999-12-31
BCBS KS Medicare
Profee · CAVANAUGH · 2023-01-01 → 2999-12-31
Cigna Medicare
Profee · CAVANAUGH · 2023-01-01 → 2999-12-31
BCBS KS Medicare, BCBS Medicare Plans
Profee · STILES · 2023-01-01 → 2999-12-31
UHC VACCN
Profee · MCPEAK · 2023-01-01 → 2999-12-31
United Healthcare Medicare
Profee · OPHC_NEXTGEN · 2023-01-01 → 2999-12-31
Cigna Medicare
Profee · OPHC_NEXTGEN · 2024-01-01 → 2999-12-31
Cigna Medicare
Profee · QUANTUM · 2023-01-01 → 2999-12-31
UHC VACCN, United Healthcare Medicare
Profee · QUANTUM · 2023-01-01 → 2999-12-31
UHC VACCN
Profee · HOLCOMB · 2023-01-01 → 2999-12-31
UHC VACCN
Profee · TUSCALOOSA · 2023-01-01 → 2999-12-31
Cigna Medicare
Profee · HOLCOMB · 2023-01-01 → 2999-12-31
UHC VACCN
Profee · PADUCAH · 2023-01-01 → 2999-12-31
Cigna Medicare
Profee · ECP_NEXTGEN, OK · 2023-01-01 → 2999-12-31
Centene Medicare
Profee · ECP_NEXTGEN, OK · 2023-01-01 → 2999-12-31
BCBS Medicare Plans
Profee · ECP_NEXTGEN, OK · 2024-01-15 → 2999-12-31
United Healthcare Medicare
Profee · EYECARE_TYLER · 2023-01-01 → 2999-12-31
United Healthcare Medicare
Profee · CVP_MIDWEST, NOVUS, RS_OHIO · 2024-01-01 → 2999-12-31
United Healthcare Medicare
Profee · GRENE_VISION · 2019-04-01 → 2999-12-31
Base terms — first match wins
  1. flat $0 — when NoncoverageStatus Noncovered is present
  2. 100% of Medicare lab
  3. 100% of Medicare drug
  4. 100% of Medicare DME
  5. 100% of Medicare RVU — when PlaceOfService 2 is present
  6. 100% of Medicare RVU
  7. 0% of billed charges
Adjustments — all apply, in order
  1. Medicare multiple-endoscopy reduction
  2. Medicare multiple-radiology reduction — base codes 4
  3. Medicare bilateral-surgery adjustment
  4. Medicare multiple-procedure reduction — base codes 2, 3; pays 100/50% — when Modifier 55 is absent; Modifier 82 is absent
  5. mid-level provider reduction (by NUCC taxonomy)
  6. modifier 22 present → 135% of the running amount
  7. modifier 52 present → 50% of the running amount
  8. modifier 54 present → 80% of the running amount
  9. custom SQL — Same global-surgery post-op allocation as hash c5fd5754fcf4a52d (Allowed/GlobalDays*PostOpRate), but hardened: falls back to returning {Allowed} unchanged when GLOB_DAYS or POST_OP is missing/non-numeric/zero instead of dividing by zero. — when Modifier 55 is present
  10. modifier 62 present → 62.5% of the running amount
  11. modifier 73 present → 50% of the running amount
  12. modifier 78 present → 70% of the running amount
  13. modifier 80 present → 16% of the running amount
  14. modifier 81 present → 16% of the running amount
  15. modifier 82 present → 16% of the running amount
  16. modifier AS present → 14% of the running amount
  17. modifier QY present → 50% of the running amount
  18. modifier QK present → 50% of the running amount
  19. modifier QX present → 50% of the running amount
  20. cap each charge and the account total at 100% of billed charges
Medicare-ASC5 base · 21 adj
Sentara Commercial
Facility · CVP_MIDATLANTIC · 2023-01-01 → 2999-12-31
Base terms — first match wins
  1. flat $0 — when NoncoverageStatus Noncovered is present
  2. 10% of billed charges — when Modifier 73 is present
  3. 20% of billed charges — when Modifier 74 is present
  4. 100% of Medicare ASC
  5. flat $0
Adjustments — all apply, in order
  1. multiple-surgery reduction (contract rules) — pays 100/50%
  2. Medicare multiple-procedure reduction — base codes 2; pays 100/50%
  3. Medicare multiple-endoscopy reduction
  4. Medicare multiple-radiology reduction — base codes 4
  5. Medicare bilateral-surgery adjustment
  6. mid-level provider reduction (by NUCC taxonomy)
  7. modifier 22 present → 135% of the running amount
  8. modifier 52 present → 50% of the running amount
  9. custom SQL — Same global-surgery post-op allocation as hash c5fd5754fcf4a52d (Allowed/GlobalDays*PostOpRate), but hardened: falls back to returning {Allowed} unchanged when GLOB_DAYS or POST_OP is missing/non-numeric/zero instead of dividing by zero. — when Modifier 55 is present
  10. modifier 54 present → 80% of the running amount
  11. modifier 62 present → 62.5% of the running amount
  12. modifier 73 present → 50% of the running amount
  13. modifier 78 present → 70% of the running amount
  14. modifier 80 present → 16% of the running amount
  15. modifier 81 present → 16% of the running amount
  16. modifier 82 present → 16% of the running amount
  17. modifier AS present → 14% of the running amount
  18. modifier QY present → 50% of the running amount
  19. modifier QK present → 50% of the running amount
  20. modifier QX present → 50% of the running amount
  21. cap each charge and the account total at 100% of billed charges
Medicare-ASC4 base · 21 adj
Humana Medicare
Facility · CVP_MIDATLANTIC, RIV · 2023-01-01 → 2999-12-31
Aetna BetterHealth Medicare
Facility · CVP_MIDATLANTIC · 2023-01-01 → 2999-12-31
Clear Spring Medicare
Facility · CVP_MIDATLANTIC · 2022-10-01 → 2999-12-31
Lifeworks Medicare
Facility · CVP_MIDATLANTIC · 2022-10-01 → 2999-12-31
Align Medicare
Facility · CVP_MIDATLANTIC · 2022-10-01 → 2999-12-31
Cigna Medicare
Facility · SABATES_EYE · 2020-01-01 → 2999-12-31
BCBS KS Medicare
Facility · SABATES_EYE · 2022-10-01 → 2999-12-31
Caresource
Facility · RAK · 2021-01-01 → 2999-12-31
Medicare
Facility · all facilities · 2023-01-01 → 2999-12-31
Humana Medicare
Facility · RAK · 2024-05-01 → 2999-12-31
HAP Medicare
Facility · ASSOCIATED_RETINAL · 2023-01-01 → 2999-12-31
Humana Medicare
Facility · ASSOCIATED_RETINAL · 2023-01-01 → 2999-12-31
McClaren Medicare
Facility · ASSOCIATED_RETINAL · 2023-01-01 → 2999-12-31
Meridian Medicare
Facility · ASSOCIATED_RETINAL · 2023-01-01 → 2999-12-31
Molina
Facility · ASSOCIATED_RETINAL · 2023-01-01 → 2999-12-31
Priority Health Medicare
Facility · ASSOCIATED_RETINAL · 2023-01-01 → 2999-12-31
Reliance Medicare
Facility · ASSOCIATED_RETINAL · 2023-01-01 → 2999-12-31
Aetna BetterHealth Medicare, Aetna Cofinity Medicare, Sentara Medicare
Facility · BSV_EyeClinicMichigan · 2023-01-01 → 2999-12-31
HAP Medicare
Facility · BSV_EyeClinicMichigan · 2023-01-01 → 2999-12-31
Humana Medicare
Facility · BSV_EyeClinicMichigan · 2023-01-01 → 2999-12-31
McClaren Medicare
Facility · BSV_EyeClinicMichigan · 2023-01-01 → 2999-12-31
Meridian Medicare
Facility · BSV_EyeClinicMichigan · 2023-01-01 → 2999-12-31
Molina Exchange, Molina Medicare
Facility · BSV_EyeClinicMichigan · 2023-01-01 → 2999-12-31
Priority Health Medicare
Facility · BSV_EyeClinicMichigan · 2023-01-01 → 2999-12-31
Reliance Medicare
Facility · BSV_EyeClinicMichigan · 2023-01-01 → 2999-12-31
Meridian Medicare
Facility · BSV_GRO · 2023-01-01 → 2999-12-31
MHP Medicare
Facility · HURON_OPH · 2023-01-01 → 2999-12-31
Humana Medicare
Facility · BSV_TukelEye · 2023-01-01 → 2999-12-31
Humana Medicare
Facility · BYRD_AND_WYAN · 2023-01-01 → 2999-12-31
Priority Health Medicare
Facility · BYRD_AND_WYAN · 2023-01-01 → 2999-12-31
United Healthcare Medicare
Facility · BYRD_AND_WYAN · 2023-01-01 → 2999-12-31
Cigna Medicare
Facility · EIWF · 2023-01-01 → 2999-12-31
Devoted Medicare
Facility · EIWF · 2023-01-01 → 2999-12-31
Multiplan Medicare
Facility · EIWF · 2023-01-01 → 2999-12-31
Aetna Cofinity Medicare
Facility · LargoASC · 2023-01-01 → 2999-12-31
BayCare
Facility · LargoASC · 2023-01-01 → 2999-12-31
BCBS Medicare Plans
Facility · LargoASC · 2023-01-01 → 2999-12-31
Cigna Medicare
Facility · LargoASC · 2023-01-01 → 2999-12-31
Amerihealth
Facility · Monmouth · 2023-01-01 → 2999-12-31
Cigna Medicare
Facility · Monmouth · 2023-01-01 → 2999-12-31
Clover Health
Facility · Monmouth · 2023-01-01 → 2999-12-31
Priority Health Medicare
Facility · OAKLAND_OPH · 2023-01-01 → 2999-12-31
United Healthcare Medicare
Facility · OAKLAND_OPH · 2023-01-01 → 2999-12-31
BCBS Medicare Plans
Facility · SOUTHGATE · 2023-01-01 → 2999-12-31
HAP Medicare
Facility · SOUTHGATE · 2023-01-01 → 2999-12-31
Humana Medicare
Facility · SOUTHGATE · 2023-01-01 → 2999-12-31
Priority Health Medicare
Facility · SOUTHGATE · 2023-01-01 → 2999-12-31
BayCare
Facility · StPetersburgASC · 2023-01-01 → 2999-12-31
BCBS Medicare Plans
Facility · StPetersburgASC · 2023-01-01 → 2999-12-31
Cigna, Cigna Medicare
Facility · StPetersburgASC · 2023-01-01 → 2999-12-31
Multiplan Medicare
Facility · StPetersburgASC · 2023-01-01 → 2999-12-31
Molina, Molina Exchange, Molina Medicare
Facility · WalkerSurgeryCenter · 2023-01-01 → 2999-12-31
HAP Medicare
Facility · HURON_OPH · 2023-01-01 → 2999-12-31
HAP Medicare
Facility · BSV · 2023-01-01 → 2999-12-31
Cigna
Facility · LargoASC · 2023-01-01 → 2024-05-31
Cigna Medicare
Facility · CVP_MIDWEST, NOVUS, RS_OHIO · 2023-01-01 → 2999-12-31
Humana Medicare
Facility · CVP_MIDWEST, NOVUS, RS_OHIO · 2023-01-01 → 2999-12-31
Aetna BetterHealth Medicare
Facility · CVP_MIDWEST, NOVUS, RS_OHIO · 2023-01-01 → 2999-12-31
Humana Medicare
Facility · MCPEAK · 2023-01-01 → 2999-12-31
Centene Medicare
Facility · CATARACT_IOK · 2023-01-01 → 2999-12-31
Cigna Medicare
Facility · CATARACT_IOK · 2023-01-01 → 2999-12-31
Humana Medicare
Facility · KENYON_ASC_NEXTGEN · 2023-01-01 → 2999-12-31
Cigna Medicare
Facility · PRECISION_VISION · 2023-01-01 → 2999-12-31
Centene Medicare
Facility · PRECISION_VISION · 2023-01-01 → 2999-12-31
Base terms — first match wins
  1. flat $0 — when NoncoverageStatus Noncovered is present
  2. 100% of Medicare ASC
  3. 100% of Medicare ASC (rates as of 2024-01-01) — when ProcedureCode 66821 is present
  4. flat $0
Adjustments — all apply, in order
  1. multiple-surgery reduction (contract rules) — pays 100/50%
  2. Medicare multiple-procedure reduction — base codes 2; pays 100/50%
  3. Medicare multiple-endoscopy reduction
  4. Medicare multiple-radiology reduction — base codes 4
  5. Medicare bilateral-surgery adjustment
  6. mid-level provider reduction (by NUCC taxonomy)
  7. modifier 22 present → 135% of the running amount
  8. modifier 52 present → 50% of the running amount
  9. custom SQL — Same global-surgery post-op allocation as hash c5fd5754fcf4a52d (Allowed/GlobalDays*PostOpRate), but hardened: falls back to returning {Allowed} unchanged when GLOB_DAYS or POST_OP is missing/non-numeric/zero instead of dividing by zero. — when Modifier 55 is present
  10. modifier 54 present → 80% of the running amount
  11. modifier 62 present → 62.5% of the running amount
  12. modifier 73 present → 50% of the running amount
  13. modifier 78 present → 70% of the running amount
  14. modifier 80 present → 16% of the running amount
  15. modifier 81 present → 16% of the running amount
  16. modifier 82 present → 16% of the running amount
  17. modifier AS present → 14% of the running amount
  18. modifier QY present → 50% of the running amount
  19. modifier QK present → 50% of the running amount
  20. modifier QX present → 50% of the running amount
  21. cap each charge and the account total at 100% of billed charges
Medicare-ASC-OphthalmologyAdj4 base · 22 adj
Anthem Medicare
Facility · RAK · 2024-09-01 → 2999-12-31
Anthem Medicare
Facility · CVP_MIDATLANTIC, RIV · 2023-01-01 → 2999-12-31
Anthem Medicare
Facility · CVP_MIDWEST, NOVUS, RS_OHIO · 2023-01-01 → 2999-12-31
Anthem Medicare
Facility · MCPEAK · 2023-01-01 → 2999-12-31
Base terms — first match wins
  1. flat $0 — when NoncoverageStatus Noncovered is present
  2. 100% of Medicare ASC
  3. 100% of Medicare ASC (rates as of 2024-01-01) — when ProcedureCode 66821 is present
  4. flat $0
Adjustments — all apply, in order
  1. multiple-surgery reduction (contract rules) — pays 100/50%
  2. Medicare multiple-ophthalmology reduction — base codes 7; pays 100/80%
  3. Medicare multiple-procedure reduction — base codes 2; pays 100/50%
  4. Medicare multiple-endoscopy reduction
  5. Medicare multiple-radiology reduction — base codes 4
  6. Medicare bilateral-surgery adjustment
  7. mid-level provider reduction (by NUCC taxonomy)
  8. modifier 22 present → 135% of the running amount
  9. modifier 52 present → 50% of the running amount
  10. custom SQL — Same global-surgery post-op allocation as hash c5fd5754fcf4a52d (Allowed/GlobalDays*PostOpRate), but hardened: falls back to returning {Allowed} unchanged when GLOB_DAYS or POST_OP is missing/non-numeric/zero instead of dividing by zero. — when Modifier 55 is present
  11. modifier 54 present → 80% of the running amount
  12. modifier 62 present → 62.5% of the running amount
  13. modifier 73 present → 50% of the running amount
  14. modifier 78 present → 70% of the running amount
  15. modifier 80 present → 16% of the running amount
  16. modifier 81 present → 16% of the running amount
  17. modifier 82 present → 16% of the running amount
  18. modifier AS present → 14% of the running amount
  19. modifier QY present → 50% of the running amount
  20. modifier QK present → 50% of the running amount
  21. modifier QX present → 50% of the running amount
  22. cap each charge and the account total at 100% of billed charges
Medicare-ASC-OphthalmologyAdj-Aetna4 base · 22 adj
Aetna Medicare
Facility · SABATES_EYE · 2023-01-01 → 2999-12-31
Aetna Medicare
Facility · ASSOCIATED_RETINAL · 2023-01-01 → 2999-12-31
Aetna Medicare
Facility · BSV_EyeClinicMichigan · 2023-01-01 → 2999-12-31
Aetna Medicare
Facility · LargoASC · 2023-01-01 → 2999-12-31
Aetna Medicare
Facility · StPetersburgASC · 2023-01-01 → 2999-12-31
Base terms — first match wins
  1. flat $0 — when NoncoverageStatus Noncovered is present
  2. 100% of Medicare ASC
  3. 100% of Medicare ASC (rates as of 2024-01-01) — when ProcedureCode 66821 is present
  4. flat $0
Adjustments — all apply, in order
  1. multiple-surgery reduction (contract rules) — pays 100/50/25%
  2. Medicare multiple-ophthalmology reduction — base codes 7; pays 100/80%
  3. Medicare multiple-procedure reduction — base codes 2; pays 100/50/25%
  4. Medicare multiple-endoscopy reduction
  5. Medicare multiple-radiology reduction — base codes 4
  6. Medicare bilateral-surgery adjustment
  7. mid-level provider reduction (by NUCC taxonomy)
  8. modifier 22 present → 135% of the running amount
  9. modifier 52 present → 50% of the running amount
  10. custom SQL — Same global-surgery post-op allocation as hash c5fd5754fcf4a52d (Allowed/GlobalDays*PostOpRate), but hardened: falls back to returning {Allowed} unchanged when GLOB_DAYS or POST_OP is missing/non-numeric/zero instead of dividing by zero. — when Modifier 55 is present
  11. modifier 54 present → 80% of the running amount
  12. modifier 62 present → 62.5% of the running amount
  13. modifier 73 present → 50% of the running amount
  14. modifier 78 present → 70% of the running amount
  15. modifier 80 present → 16% of the running amount
  16. modifier 81 present → 16% of the running amount
  17. modifier 82 present → 16% of the running amount
  18. modifier AS present → 14% of the running amount
  19. modifier QY present → 50% of the running amount
  20. modifier QK present → 50% of the running amount
  21. modifier QX present → 50% of the running amount
  22. cap each charge and the account total at 100% of billed charges
Medicare-OphthalmologyAdj7 base · 21 adj
Anthem Medicare
Profee · RAK · 2024-09-01 → 2999-12-31
Anthem Medicare
Profee · CVP_MIDATLANTIC, RIV · 2023-01-01 → 2999-12-31
Anthem Medicare
Profee · CVP_MIDWEST, NOVUS, RS_OHIO · 2023-01-01 → 2999-12-31
Anthem Medicare
Profee · KENYON_ASC_NEXTGEN, KENYON_NEXTGEN · 2024-01-01 → 2999-12-31
Anthem Medicare
Profee · PADUCAH · 2024-09-01 → 2999-12-31
Base terms — first match wins
  1. flat $0 — when NoncoverageStatus Noncovered is present
  2. 100% of Medicare lab
  3. 100% of Medicare drug
  4. 100% of Medicare DME
  5. 100% of Medicare RVU — when PlaceOfService 2 is present
  6. 100% of Medicare RVU
  7. 0% of billed charges
Adjustments — all apply, in order
  1. Medicare multiple-ophthalmology reduction — base codes 7; pays 100/80%
  2. Medicare multiple-endoscopy reduction
  3. Medicare multiple-radiology reduction — base codes 4
  4. Medicare bilateral-surgery adjustment
  5. Medicare multiple-procedure reduction — base codes 2, 3; pays 100/50% — when Modifier 55 is absent; Modifier 82 is absent
  6. mid-level provider reduction (by NUCC taxonomy)
  7. modifier 22 present → 135% of the running amount
  8. modifier 52 present → 50% of the running amount
  9. modifier 54 present → 80% of the running amount
  10. custom SQL — Same global-surgery post-op allocation as hash c5fd5754fcf4a52d (Allowed/GlobalDays*PostOpRate), but hardened: falls back to returning {Allowed} unchanged when GLOB_DAYS or POST_OP is missing/non-numeric/zero instead of dividing by zero. — when Modifier 55 is present
  11. modifier 62 present → 62.5% of the running amount
  12. modifier 73 present → 50% of the running amount
  13. modifier 78 present → 70% of the running amount
  14. modifier 80 present → 16% of the running amount
  15. modifier 81 present → 16% of the running amount
  16. modifier 82 present → 16% of the running amount
  17. modifier AS present → 14% of the running amount
  18. modifier QY present → 50% of the running amount
  19. modifier QK present → 50% of the running amount
  20. modifier QX present → 50% of the running amount
  21. cap each charge and the account total at 100% of billed charges
Medicare-OphthalmologyAdj-Aetna7 base · 21 adj
Aetna Medicare
Profee · ASSOCIATED_RETINAL · 2023-01-01 → 2999-12-31
Aetna Medicare
Profee · BSV_EyeClinicMichigan · 2023-01-01 → 2999-12-31
Aetna Medicare
Profee · LargoASC · 2023-01-01 → 2999-12-31
Aetna Medicare
Profee · StPetersburgASC · 2023-01-01 → 2999-12-31
Aetna Medicare
Profee · CVP_MIDATLANTIC · 2023-01-01 → 2999-12-31
Aetna Medicare
Profee · GRENE_VISION · 2023-01-01 → 2999-12-31
Aetna Medicare
Profee · DEER_CREEK · 2022-02-15 → 2999-12-31
Aetna Medicare
Profee · OPHC_NEXTGEN · 2023-01-01 → 2999-12-31
Aetna Medicare
Profee · PADUCAH · 2023-01-01 → 2999-12-31
Base terms — first match wins
  1. flat $0 — when NoncoverageStatus Noncovered is present
  2. 100% of Medicare lab
  3. 100% of Medicare drug
  4. 100% of Medicare DME
  5. 100% of Medicare RVU — when PlaceOfService 2 is present
  6. 100% of Medicare RVU
  7. 0% of billed charges
Adjustments — all apply, in order
  1. Medicare multiple-ophthalmology reduction — base codes 7; pays 100/80%
  2. Medicare multiple-endoscopy reduction
  3. Medicare multiple-radiology reduction — base codes 4
  4. Medicare bilateral-surgery adjustment
  5. Medicare multiple-procedure reduction — base codes 2, 3; pays 100/50/25% — when Modifier 55 is absent; Modifier 82 is absent
  6. mid-level provider reduction (by NUCC taxonomy)
  7. modifier 22 present → 135% of the running amount
  8. modifier 52 present → 50% of the running amount
  9. modifier 54 present → 80% of the running amount
  10. custom SQL — Same global-surgery post-op allocation as hash c5fd5754fcf4a52d (Allowed/GlobalDays*PostOpRate), but hardened: falls back to returning {Allowed} unchanged when GLOB_DAYS or POST_OP is missing/non-numeric/zero instead of dividing by zero. — when Modifier 55 is present
  11. modifier 62 present → 62.5% of the running amount
  12. modifier 73 present → 50% of the running amount
  13. modifier 78 present → 70% of the running amount
  14. modifier 80 present → 16% of the running amount
  15. modifier 81 present → 16% of the running amount
  16. modifier 82 present → 16% of the running amount
  17. modifier AS present → 14% of the running amount
  18. modifier QY present → 50% of the running amount
  19. modifier QK present → 50% of the running amount
  20. modifier QX present → 50% of the running amount
  21. cap each charge and the account total at 100% of billed charges
Molina6 base · 20 adj
Molina
Profee · RAK · 2024-01-01 → 2999-12-31
Base terms — first match wins
  1. flat $0 — when NoncoverageStatus Noncovered is present
  2. 100% of the Fixed-Fees fee schedule — when PlaceOfService 81 is present
  3. 100% of the Profee-Lab fee schedule
  4. 100% of Medicare drug
  5. 100% of the Profee-Drug fee schedule
  6. 100% of the Profee-Fees fee schedule
Adjustments — all apply, in order
  1. Medicare multiple-procedure reduction — base codes 2, 3; pays 100/50% — when Modifier 55 is absent; Modifier 82 is absent
  2. Medicare multiple-endoscopy reduction
  3. Medicare multiple-radiology reduction — base codes 4
  4. Medicare bilateral-surgery adjustment
  5. mid-level provider reduction (by NUCC taxonomy)
  6. modifier 22 present → 135% of the running amount
  7. modifier 52 present → 50% of the running amount
  8. custom SQL — Same global-surgery post-op allocation as hash c5fd5754fcf4a52d (Allowed/GlobalDays*PostOpRate), but hardened: falls back to returning {Allowed} unchanged when GLOB_DAYS or POST_OP is missing/non-numeric/zero instead of dividing by zero. — when Modifier 55 is present
  9. modifier 54 present → 80% of the running amount
  10. modifier 62 present → 62.5% of the running amount
  11. modifier 73 present → 50% of the running amount
  12. modifier 78 present → 70% of the running amount
  13. modifier 80 present → 16% of the running amount
  14. modifier 81 present → 16% of the running amount
  15. modifier 82 present → 16% of the running amount
  16. modifier AS present → 14% of the running amount
  17. modifier QY present → 50% of the running amount
  18. modifier QK present → 50% of the running amount
  19. modifier QX present → 50% of the running amount
  20. cap each charge and the account total at 100% of billed charges
Molina-Medicare6 base · 20 adj
Molina
Profee · RAK · 2024-01-01 → 2999-12-31
Base terms — first match wins
  1. flat $0 — when NoncoverageStatus Noncovered is present
  2. 100% of the Fixed-Fees fee schedule — when PlaceOfService 81 is present
  3. 100% of the Profee-Lab fee schedule
  4. 100% of Medicare drug
  5. 100% of the Profee-Drug fee schedule
  6. 100% of the Profee-Fees fee schedule
Adjustments — all apply, in order
  1. Medicare multiple-procedure reduction — base codes 2, 3; pays 100/50% — when Modifier 55 is absent; Modifier 82 is absent
  2. Medicare multiple-endoscopy reduction
  3. Medicare multiple-radiology reduction — base codes 4
  4. Medicare bilateral-surgery adjustment
  5. mid-level provider reduction (by NUCC taxonomy)
  6. modifier 22 present → 135% of the running amount
  7. modifier 52 present → 50% of the running amount
  8. custom SQL — Same global-surgery post-op allocation as hash c5fd5754fcf4a52d (Allowed/GlobalDays*PostOpRate), but hardened: falls back to returning {Allowed} unchanged when GLOB_DAYS or POST_OP is missing/non-numeric/zero instead of dividing by zero. — when Modifier 55 is present
  9. modifier 54 present → 80% of the running amount
  10. modifier 62 present → 62.5% of the running amount
  11. modifier 73 present → 50% of the running amount
  12. modifier 78 present → 70% of the running amount
  13. modifier 80 present → 16% of the running amount
  14. modifier 81 present → 16% of the running amount
  15. modifier 82 present → 16% of the running amount
  16. modifier AS present → 14% of the running amount
  17. modifier QY present → 50% of the running amount
  18. modifier QK present → 50% of the running amount
  19. modifier QX present → 50% of the running amount
  20. cap each charge and the account total at 100% of billed charges
Monmouth 100% Profee Fees Schedule3 base · 20 adj
BCBS Commercial Plans, BCBS Federal
Profee · MONMOUTH_RETINA · 2025-02-19 → 2999-12-31
United Healthcare
Profee · MONMOUTH_RETINA · 2025-01-01 → 2999-12-31
Base terms — first match wins
  1. flat $0 — when NoncoverageStatus Noncovered is present
  2. 100% of Medicare drug
  3. 100% of the MonmouthRetina-Profee-Fees fee schedule
Adjustments — all apply, in order
  1. Medicare multiple-procedure reduction — base codes 2, 3; pays 100/50% — when Modifier 55 is absent; Modifier 82 is absent
  2. Medicare multiple-endoscopy reduction
  3. Medicare multiple-radiology reduction — base codes 4
  4. Medicare bilateral-surgery adjustment
  5. mid-level provider reduction (by NUCC taxonomy)
  6. modifier 22 present → 135% of the running amount
  7. modifier 52 present → 50% of the running amount
  8. custom SQL — Same global-surgery post-op allocation as hash c5fd5754fcf4a52d (Allowed/GlobalDays*PostOpRate), but hardened: falls back to returning {Allowed} unchanged when GLOB_DAYS or POST_OP is missing/non-numeric/zero instead of dividing by zero. — when Modifier 55 is present
  9. modifier 54 present → 80% of the running amount
  10. modifier 62 present → 62.5% of the running amount
  11. modifier 73 present → 50% of the running amount
  12. modifier 78 present → 70% of the running amount
  13. modifier 80 present → 16% of the running amount
  14. modifier 81 present → 16% of the running amount
  15. modifier 82 present → 16% of the running amount
  16. modifier AS present → 14% of the running amount
  17. modifier QY present → 50% of the running amount
  18. modifier QK present → 50% of the running amount
  19. modifier QX present → 50% of the running amount
  20. cap each charge and the account total at 100% of billed charges
Monmouth Aetna Profee3 base · 20 adj
Aetna
Profee · MONMOUTH_RETINA · 2025-06-01 → 2026-05-31
Base terms — first match wins
  1. flat $0 — when NoncoverageStatus Noncovered is present
  2. 100% of Medicare drug
  3. 120% of the MonmouthRetina-Profee-Fees fee schedule
Adjustments — all apply, in order
  1. Medicare multiple-procedure reduction — base codes 2, 3; pays 100/50% — when Modifier 55 is absent; Modifier 82 is absent
  2. Medicare multiple-endoscopy reduction
  3. Medicare multiple-radiology reduction — base codes 4
  4. Medicare bilateral-surgery adjustment
  5. mid-level provider reduction (by NUCC taxonomy)
  6. modifier 22 present → 135% of the running amount
  7. modifier 52 present → 50% of the running amount
  8. custom SQL — Same global-surgery post-op allocation as hash c5fd5754fcf4a52d (Allowed/GlobalDays*PostOpRate), but hardened: falls back to returning {Allowed} unchanged when GLOB_DAYS or POST_OP is missing/non-numeric/zero instead of dividing by zero. — when Modifier 55 is present
  9. modifier 54 present → 80% of the running amount
  10. modifier 62 present → 62.5% of the running amount
  11. modifier 73 present → 50% of the running amount
  12. modifier 78 present → 70% of the running amount
  13. modifier 80 present → 16% of the running amount
  14. modifier 81 present → 16% of the running amount
  15. modifier 82 present → 16% of the running amount
  16. modifier AS present → 14% of the running amount
  17. modifier QY present → 50% of the running amount
  18. modifier QK present → 50% of the running amount
  19. modifier QX present → 50% of the running amount
  20. cap each charge and the account total at 100% of billed charges
Monmouth Aetna Profee3 base · 20 adj
Aetna
Profee · MONMOUTH_RETINA · 2026-06-01 → 2027-05-31
Base terms — first match wins
  1. flat $0 — when NoncoverageStatus Noncovered is present
  2. 100% of Medicare drug
  3. 125% of the MonmouthRetina-Profee-Fees fee schedule
Adjustments — all apply, in order
  1. Medicare multiple-procedure reduction — base codes 2, 3; pays 100/50% — when Modifier 55 is absent; Modifier 82 is absent
  2. Medicare multiple-endoscopy reduction
  3. Medicare multiple-radiology reduction — base codes 4
  4. Medicare bilateral-surgery adjustment
  5. mid-level provider reduction (by NUCC taxonomy)
  6. modifier 22 present → 135% of the running amount
  7. modifier 52 present → 50% of the running amount
  8. custom SQL — Same global-surgery post-op allocation as hash c5fd5754fcf4a52d (Allowed/GlobalDays*PostOpRate), but hardened: falls back to returning {Allowed} unchanged when GLOB_DAYS or POST_OP is missing/non-numeric/zero instead of dividing by zero. — when Modifier 55 is present
  9. modifier 54 present → 80% of the running amount
  10. modifier 62 present → 62.5% of the running amount
  11. modifier 73 present → 50% of the running amount
  12. modifier 78 present → 70% of the running amount
  13. modifier 80 present → 16% of the running amount
  14. modifier 81 present → 16% of the running amount
  15. modifier 82 present → 16% of the running amount
  16. modifier AS present → 14% of the running amount
  17. modifier QY present → 50% of the running amount
  18. modifier QK present → 50% of the running amount
  19. modifier QX present → 50% of the running amount
  20. cap each charge and the account total at 100% of billed charges
Monmouth Cigna Profee Fees4 base · 20 adj
Cigna
Profee · MONMOUTH_RETINA · 2025-01-01 → 2999-12-31
Base terms — first match wins
  1. flat $0 — when NoncoverageStatus Noncovered is present
  2. 100% of Medicare drug
  3. 100% of the MonmouthRetina-Profee-Fees fee schedule
  4. percent-of-charges, rate read from the MonmouthRetina-Percent-Fees schedule
Adjustments — all apply, in order
  1. Medicare multiple-procedure reduction — base codes 2, 3; pays 100/50% — when Modifier 55 is absent; Modifier 82 is absent
  2. Medicare multiple-endoscopy reduction
  3. Medicare multiple-radiology reduction — base codes 4
  4. Medicare bilateral-surgery adjustment
  5. mid-level provider reduction (by NUCC taxonomy)
  6. modifier 22 present → 135% of the running amount
  7. modifier 52 present → 50% of the running amount
  8. custom SQL — Same global-surgery post-op allocation as hash c5fd5754fcf4a52d (Allowed/GlobalDays*PostOpRate), but hardened: falls back to returning {Allowed} unchanged when GLOB_DAYS or POST_OP is missing/non-numeric/zero instead of dividing by zero. — when Modifier 55 is present
  9. modifier 54 present → 80% of the running amount
  10. modifier 62 present → 62.5% of the running amount
  11. modifier 73 present → 50% of the running amount
  12. modifier 78 present → 70% of the running amount
  13. modifier 80 present → 16% of the running amount
  14. modifier 81 present → 16% of the running amount
  15. modifier 82 present → 16% of the running amount
  16. modifier AS present → 14% of the running amount
  17. modifier QY present → 50% of the running amount
  18. modifier QK present → 50% of the running amount
  19. modifier QX present → 50% of the running amount
  20. cap each charge and the account total at 100% of billed charges
Monmouth-CloverHealth7 base · 20 adj
Clover Health
Profee · MONMOUTH_RETINA · 2025-01-01 → 2999-12-31
Base terms — first match wins
  1. flat $0 — when NoncoverageStatus Noncovered is present
  2. 100% of Medicare lab
  3. 100% of Medicare drug
  4. 100% of Medicare DME
  5. 100% of Medicare RVU — when PlaceOfService 2 is present
  6. 100% of Medicare RVU
  7. 0% of billed charges
Adjustments — all apply, in order
  1. Medicare multiple-endoscopy reduction
  2. Medicare multiple-radiology reduction — base codes 4
  3. Medicare bilateral-surgery adjustment
  4. Medicare multiple-procedure reduction — base codes 2, 3; pays 100/50% — when Modifier 55 is absent; Modifier 82 is absent
  5. mid-level provider reduction (by NUCC taxonomy)
  6. modifier 22 present → 135% of the running amount
  7. modifier 52 present → 50% of the running amount
  8. modifier 54 present → 80% of the running amount
  9. custom SQL — Same global-surgery post-op allocation as hash c5fd5754fcf4a52d (Allowed/GlobalDays*PostOpRate), but hardened: falls back to returning {Allowed} unchanged when GLOB_DAYS or POST_OP is missing/non-numeric/zero instead of dividing by zero. — when Modifier 55 is present
  10. modifier 62 present → 62.5% of the running amount
  11. modifier 73 present → 50% of the running amount
  12. modifier 78 present → 70% of the running amount
  13. modifier 80 present → 16% of the running amount
  14. modifier 81 present → 16% of the running amount
  15. modifier 82 present → 16% of the running amount
  16. modifier AS present → 14% of the running amount
  17. modifier QY present → 50% of the running amount
  18. modifier QK present → 50% of the running amount
  19. modifier QX present → 50% of the running amount
  20. cap each charge and the account total at 100% of billed charges
OH Medicaid Profees6 base · 20 adj
Medicaid
Profee · OH · 2023-01-01 → 2999-12-31
Aetna BetterHealth Medicaid, Aetna Medicaid
Profee · CVP_MIDWEST, NOVUS, RS_OHIO, OH · 2023-01-01 → 2999-12-31
Anthem Medicaid, BCBS Medicaid Plans
Profee · CVP_MIDWEST, NOVUS, RS_OHIO, OH · 2023-01-01 → 2999-12-31
Buckeye Medicaid
Profee · CVP_MIDWEST, NOVUS, RS_OHIO, OH · 2023-01-01 → 2999-12-31
Humana Medicaid
Profee · CVP_MIDWEST, NOVUS, RS_OHIO, OH · 2023-01-01 → 2999-12-31
United Healthcare Medicaid
Profee · CVP_MIDWEST, NOVUS, RS_OHIO, OH · 2023-01-01 → 2999-12-31
Molina Medicaid
Profee · CVP_MIDWEST, NOVUS, RS_OHIO, OH · 2023-01-01 → 2999-12-31
Base terms — first match wins
  1. flat $0 — when NoncoverageStatus Noncovered is present
  2. 100% of Medicare drug
  3. 100% of the OH-Medicaid-Fixed-Fees-DME fee schedule
  4. 100% of the OH-Medicaid-Fixed-Fees-Labs fee schedule
  5. 100% of the OH-Medicaid-Facility-Profee-Fees fee schedule — when FacilityType in ASC, Hospital, Home
  6. 100% of the OH-Medicaid-Profee-Fees fee schedule
Adjustments — all apply, in order
  1. Medicare multiple-procedure reduction — base codes 2, 3; pays 100/50% — when Modifier 55 is absent; Modifier 82 is absent
  2. Medicare multiple-endoscopy reduction
  3. Medicare multiple-radiology reduction — base codes 4
  4. Medicare bilateral-surgery adjustment
  5. mid-level provider reduction (by NUCC taxonomy)
  6. modifier 22 present → 135% of the running amount
  7. modifier 52 present → 50% of the running amount
  8. custom SQL — Same global-surgery post-op allocation as hash c5fd5754fcf4a52d (Allowed/GlobalDays*PostOpRate), but hardened: falls back to returning {Allowed} unchanged when GLOB_DAYS or POST_OP is missing/non-numeric/zero instead of dividing by zero. — when Modifier 55 is present
  9. modifier 54 present → 80% of the running amount
  10. modifier 62 present → 62.5% of the running amount
  11. modifier 73 present → 50% of the running amount
  12. modifier 78 present → 70% of the running amount
  13. modifier 80 present → 16% of the running amount
  14. modifier 81 present → 16% of the running amount
  15. modifier 82 present → 16% of the running amount
  16. modifier AS present → 14% of the running amount
  17. modifier QY present → 50% of the running amount
  18. modifier QK present → 50% of the running amount
  19. modifier QX present → 50% of the running amount
  20. cap each charge and the account total at 100% of billed charges
OH-UHC Facility Fees2 base · 21 adj
United Healthcare
Facility · CVP_MIDWEST, NOVUS · 2024-01-01 → 2999-12-31
Base terms — first match wins
  1. flat $0 — when NoncoverageStatus Noncovered is present
  2. 100% of the Ohio-UHC-Facility-Fees fee schedule
Adjustments — all apply, in order
  1. Medicare multiple-procedure reduction — base codes 2, 3; pays 100/50/0% — when Modifier 55 is absent
  2. Medicare multiple-endoscopy reduction
  3. Medicare multiple-radiology reduction — base codes 4
  4. Medicare bilateral-surgery adjustment
  5. mid-level provider reduction (by NUCC taxonomy)
  6. modifier 22 present → 135% of the running amount
  7. modifier 53 present → 25% of the running amount
  8. modifier 52 present → 50% of the running amount
  9. custom SQL — Same global-surgery post-op allocation as hash c5fd5754fcf4a52d (Allowed/GlobalDays*PostOpRate), but hardened: falls back to returning {Allowed} unchanged when GLOB_DAYS or POST_OP is missing/non-numeric/zero instead of dividing by zero. — when Modifier 55 is present
  10. modifier 54 present → 80% of the running amount
  11. modifier 62 present → 62.5% of the running amount
  12. modifier 73 present → 50% of the running amount
  13. modifier 78 present → 70% of the running amount
  14. modifier 80 present → 16% of the running amount
  15. modifier 81 present → 16% of the running amount
  16. modifier 82 present → 16% of the running amount
  17. modifier AS present → 14% of the running amount
  18. modifier QY present → 50% of the running amount
  19. modifier QK present → 50% of the running amount
  20. modifier QX present → 50% of the running amount
  21. cap each charge and the account total at 100% of billed charges
OK Medicaid Facility Fees3 base · 21 adj
Aetna Medicaid
Facility · CATARACT_IOK · 2023-01-01 → 2999-12-31
Centene Medicaid
Facility · CATARACT_IOK · 2023-01-01 → 2999-12-31
Base terms — first match wins
  1. flat $0 — when NoncoverageStatus Noncovered is present
  2. 100% of the Facility-Fees fee schedule
  3. 0% of billed charges
Adjustments — all apply, in order
  1. multiple-surgery reduction (contract rules) — pays 100/50%
  2. Medicare multiple-procedure reduction — base codes 2; pays 100/50%
  3. Medicare multiple-endoscopy reduction
  4. Medicare multiple-radiology reduction — base codes 4
  5. Medicare bilateral-surgery adjustment
  6. mid-level provider reduction (by NUCC taxonomy)
  7. modifier 22 present → 135% of the running amount
  8. modifier 52 present → 50% of the running amount
  9. custom SQL — Same global-surgery post-op allocation as hash c5fd5754fcf4a52d (Allowed/GlobalDays*PostOpRate), but hardened: falls back to returning {Allowed} unchanged when GLOB_DAYS or POST_OP is missing/non-numeric/zero instead of dividing by zero. — when Modifier 55 is present
  10. modifier 54 present → 80% of the running amount
  11. modifier 62 present → 62.5% of the running amount
  12. modifier 73 present → 50% of the running amount
  13. modifier 78 present → 70% of the running amount
  14. modifier 80 present → 16% of the running amount
  15. modifier 81 present → 16% of the running amount
  16. modifier 82 present → 16% of the running amount
  17. modifier AS present → 14% of the running amount
  18. modifier QY present → 50% of the running amount
  19. modifier QK present → 50% of the running amount
  20. modifier QX present → 50% of the running amount
  21. cap each charge and the account total at 100% of billed charges
OK Medicaid Profees5 base · 20 adj
Aetna Medicaid
Profee · CATARACT_IOK · 2023-01-01 → 2999-12-31
Centene Medicaid
Profee · CATARACT_IOK · 2023-01-01 → 2999-12-31
Base terms — first match wins
  1. flat $0 — when NoncoverageStatus Noncovered is present
  2. 100% of the OK-Medicaid-DME-Fixed-Fees fee schedule
  3. 100% of the OK-Medicaid-Facility-Profee-Fees fee schedule — when FacilityType in Hospital, Home, ASC
  4. 100% of the OK-Medicaid-Profee-Fees fee schedule — when FacilityType in Clinic
  5. 0% of billed charges
Adjustments — all apply, in order
  1. Medicare multiple-procedure reduction — base codes 2, 3; pays 100/50% — when Modifier 55 is absent; Modifier 82 is absent
  2. Medicare multiple-endoscopy reduction
  3. Medicare multiple-radiology reduction — base codes 4
  4. Medicare bilateral-surgery adjustment
  5. mid-level provider reduction (by NUCC taxonomy)
  6. modifier 22 present → 135% of the running amount
  7. modifier 52 present → 50% of the running amount
  8. custom SQL — Same global-surgery post-op allocation as hash c5fd5754fcf4a52d (Allowed/GlobalDays*PostOpRate), but hardened: falls back to returning {Allowed} unchanged when GLOB_DAYS or POST_OP is missing/non-numeric/zero instead of dividing by zero. — when Modifier 55 is present
  9. modifier 54 present → 80% of the running amount
  10. modifier 62 present → 62.5% of the running amount
  11. modifier 73 present → 50% of the running amount
  12. modifier 78 present → 70% of the running amount
  13. modifier 80 present → 16% of the running amount
  14. modifier 81 present → 16% of the running amount
  15. modifier 82 present → 16% of the running amount
  16. modifier AS present → 14% of the running amount
  17. modifier QY present → 50% of the running amount
  18. modifier QK present → 50% of the running amount
  19. modifier QX present → 50% of the running amount
  20. cap each charge and the account total at 100% of billed charges
OK-Humana Profees4 base · 20 adj
Humana
Profee · ASC, Clinic, Home, Hospital, OK · 2023-01-01 → 2999-12-31
Base terms — first match wins
  1. flat $0 — when NoncoverageStatus Noncovered is present
  2. 100% of Medicare drug
  3. 100% of the OK-Humana-Profee-Fees fee schedule — when FacilityType in Clinic
  4. 100% of the OK-Humana-Facility-Profee-Fees fee schedule — when FacilityType in ASC, Hospital, Home
Adjustments — all apply, in order
  1. Medicare multiple-procedure reduction — base codes 2, 3; pays 100/50% — when Modifier 55 is absent; Modifier 82 is absent
  2. Medicare multiple-endoscopy reduction
  3. Medicare multiple-radiology reduction — base codes 4
  4. Medicare bilateral-surgery adjustment
  5. mid-level provider reduction (by NUCC taxonomy)
  6. modifier 22 present → 135% of the running amount
  7. modifier 52 present → 50% of the running amount
  8. custom SQL — Same global-surgery post-op allocation as hash c5fd5754fcf4a52d (Allowed/GlobalDays*PostOpRate), but hardened: falls back to returning {Allowed} unchanged when GLOB_DAYS or POST_OP is missing/non-numeric/zero instead of dividing by zero. — when Modifier 55 is present
  9. modifier 54 present → 80% of the running amount
  10. modifier 62 present → 62.5% of the running amount
  11. modifier 73 present → 50% of the running amount
  12. modifier 78 present → 70% of the running amount
  13. modifier 80 present → 16% of the running amount
  14. modifier 81 present → 16% of the running amount
  15. modifier 82 present → 16% of the running amount
  16. modifier AS present → 14% of the running amount
  17. modifier QY present → 50% of the running amount
  18. modifier QK present → 50% of the running amount
  19. modifier QX present → 50% of the running amount
  20. cap each charge and the account total at 100% of billed charges
Ohio - 6 Degrees Facility Fees3 base · 21 adj
6 Degrees
Facility · CVP_MIDWEST, NOVUS, RS_OHIO · 2024-01-01 → 2999-12-31
Base terms — first match wins
  1. flat $0 — when NoncoverageStatus Noncovered is present
  2. 140% of Medicare ASC ⚠︎ named “180% Medicare - ASC” but configured at 140%
  3. flat $0
Adjustments — all apply, in order
  1. multiple-surgery reduction (contract rules) — pays 100/50%
  2. Medicare multiple-procedure reduction — base codes 2; pays 100/50%
  3. Medicare multiple-endoscopy reduction
  4. Medicare multiple-radiology reduction — base codes 4
  5. Medicare bilateral-surgery adjustment
  6. mid-level provider reduction (by NUCC taxonomy)
  7. modifier 22 present → 135% of the running amount
  8. modifier 52 present → 50% of the running amount
  9. custom SQL — Same global-surgery post-op allocation as hash c5fd5754fcf4a52d (Allowed/GlobalDays*PostOpRate), but hardened: falls back to returning {Allowed} unchanged when GLOB_DAYS or POST_OP is missing/non-numeric/zero instead of dividing by zero. — when Modifier 55 is present
  10. modifier 54 present → 80% of the running amount
  11. modifier 62 present → 62.5% of the running amount
  12. modifier 73 present → 50% of the running amount
  13. modifier 78 present → 70% of the running amount
  14. modifier 80 present → 16% of the running amount
  15. modifier 81 present → 16% of the running amount
  16. modifier 82 present → 16% of the running amount
  17. modifier AS present → 14% of the running amount
  18. modifier QY present → 50% of the running amount
  19. modifier QK present → 50% of the running amount
  20. modifier QX present → 50% of the running amount
  21. cap each charge and the account total at 80% of billed charges
Ohio - Amerihealth Medicaid Profees6 base · 20 adj
Amerihealth Medicaid
Profee · CVP_MIDWEST, NOVUS, RS_OHIO, OH · 2023-01-01 → 2999-12-31
Base terms — first match wins
  1. flat $0 — when NoncoverageStatus Noncovered is present
  2. 100% of Medicare drug
  3. 103% of the Fixed-Fees-DME fee schedule
  4. 103% of the Fixed-Fees-Labs fee schedule
  5. 103% of the Profee-Fees fee schedule
  6. 0% of billed charges
Adjustments — all apply, in order
  1. Medicare multiple-procedure reduction — base codes 2, 3; pays 100/50% — when Modifier 55 is absent; Modifier 82 is absent
  2. Medicare multiple-endoscopy reduction
  3. Medicare multiple-radiology reduction — base codes 4
  4. Medicare bilateral-surgery adjustment
  5. mid-level provider reduction (by NUCC taxonomy)
  6. modifier 22 present → 135% of the running amount
  7. modifier 52 present → 50% of the running amount
  8. custom SQL — Same global-surgery post-op allocation as hash c5fd5754fcf4a52d (Allowed/GlobalDays*PostOpRate), but hardened: falls back to returning {Allowed} unchanged when GLOB_DAYS or POST_OP is missing/non-numeric/zero instead of dividing by zero. — when Modifier 55 is present
  9. modifier 54 present → 80% of the running amount
  10. modifier 62 present → 62.5% of the running amount
  11. modifier 73 present → 50% of the running amount
  12. modifier 78 present → 70% of the running amount
  13. modifier 80 present → 16% of the running amount
  14. modifier 81 present → 16% of the running amount
  15. modifier 82 present → 16% of the running amount
  16. modifier AS present → 14% of the running amount
  17. modifier QY present → 50% of the running amount
  18. modifier QK present → 50% of the running amount
  19. modifier QX present → 50% of the running amount
  20. cap each charge and the account total at 100% of billed charges
Ohio - Medical Mutual Facility Fees7 base · 20 adj
Medical Mutual Commercial
Facility · CVP_MIDWEST, NOVUS, RS_OHIO, StPetersburgASC · 2024-01-01 → 2999-12-31
Base terms — first match wins
  1. flat $0 — when NoncoverageStatus Noncovered is present
  2. 100% of billed charges — when ProcedureCode V2785 is present
  3. 100% of billed charges — when ProcedureCode J7310 is present
  4. 100% of billed charges — when ProcedureCode J7311 is present
  5. 100% of billed charges — when ProcedureCode J7312 is present
  6. 100% of the Carveouts fee schedule
  7. 100% of the Facility-Fees fee schedule
Adjustments — all apply, in order
  1. multiple-surgery reduction (contract rules) — pays 100/50%
  2. Medicare multiple-endoscopy reduction
  3. Medicare multiple-radiology reduction — base codes 4
  4. Medicare bilateral-surgery adjustment
  5. mid-level provider reduction (by NUCC taxonomy)
  6. modifier 22 present → 135% of the running amount
  7. modifier 52 present → 50% of the running amount
  8. custom SQL — Same global-surgery post-op allocation as hash c5fd5754fcf4a52d (Allowed/GlobalDays*PostOpRate), but hardened: falls back to returning {Allowed} unchanged when GLOB_DAYS or POST_OP is missing/non-numeric/zero instead of dividing by zero. — when Modifier 55 is present
  9. modifier 54 present → 80% of the running amount
  10. modifier 62 present → 62.5% of the running amount
  11. modifier 73 present → 50% of the running amount
  12. modifier 78 present → 70% of the running amount
  13. modifier 80 present → 16% of the running amount
  14. modifier 81 present → 16% of the running amount
  15. modifier 82 present → 16% of the running amount
  16. modifier AS present → 14% of the running amount
  17. modifier QY present → 50% of the running amount
  18. modifier QK present → 50% of the running amount
  19. modifier QX present → 50% of the running amount
  20. cap each charge and the account total at 100% of billed charges
Ohio-Aetna Commercial Facility Fees2 base · 21 adj
Aetna
Facility · CVP_MIDWEST, NOVUS, RS_OHIO · 2023-01-01 → 2999-12-31
Base terms — first match wins
  1. flat $0 — when NoncoverageStatus Noncovered is present
  2. case rate from CaseRate (All-level codes)
Adjustments — all apply, in order
  1. Medicare multiple-procedure reduction — base codes 2, 3; pays 100/50/25% — when Modifier 55 is absent
  2. Medicare multiple-ophthalmology reduction — base codes 7; pays 100/80%
  3. Medicare multiple-endoscopy reduction
  4. Medicare multiple-radiology reduction — base codes 4
  5. Medicare bilateral-surgery adjustment
  6. mid-level provider reduction (by NUCC taxonomy)
  7. modifier 22 present → 135% of the running amount
  8. modifier 52 present → 50% of the running amount
  9. custom SQL — Same global-surgery post-op allocation as hash c5fd5754fcf4a52d (Allowed/GlobalDays*PostOpRate), but hardened: falls back to returning {Allowed} unchanged when GLOB_DAYS or POST_OP is missing/non-numeric/zero instead of dividing by zero. — when Modifier 55 is present
  10. modifier 54 present → 80% of the running amount
  11. modifier 62 present → 62.5% of the running amount
  12. modifier 73 present → 50% of the running amount
  13. modifier 78 present → 70% of the running amount
  14. modifier 80 present → 16% of the running amount
  15. modifier 81 present → 16% of the running amount
  16. modifier 82 present → 16% of the running amount
  17. modifier AS present → 14% of the running amount
  18. modifier QY present → 50% of the running amount
  19. modifier QK present → 50% of the running amount
  20. modifier QX present → 50% of the running amount
  21. cap each charge and the account total at 100% of billed charges
Ohio-Aetna Medicare Facility Fees3 base · 22 adj
Aetna Medicare
Facility · CVP_MIDWEST, NOVUS, RS_OHIO · 2023-01-01 → 2999-12-31
Base terms — first match wins
  1. flat $0 — when NoncoverageStatus Noncovered is present
  2. 100% of Medicare ASC
  3. 30% of billed charges
Adjustments — all apply, in order
  1. multiple-surgery reduction (contract rules) — pays 100/50/25%
  2. Medicare multiple-procedure reduction — base codes 2; pays 100/50/25%
  3. Medicare multiple-ophthalmology reduction — base codes 7; pays 100/80%
  4. Medicare multiple-endoscopy reduction
  5. Medicare multiple-radiology reduction — base codes 4
  6. Medicare bilateral-surgery adjustment
  7. mid-level provider reduction (by NUCC taxonomy)
  8. modifier 22 present → 135% of the running amount
  9. modifier 52 present → 50% of the running amount
  10. custom SQL — Same global-surgery post-op allocation as hash c5fd5754fcf4a52d (Allowed/GlobalDays*PostOpRate), but hardened: falls back to returning {Allowed} unchanged when GLOB_DAYS or POST_OP is missing/non-numeric/zero instead of dividing by zero. — when Modifier 55 is present
  11. modifier 54 present → 80% of the running amount
  12. modifier 62 present → 62.5% of the running amount
  13. modifier 73 present → 50% of the running amount
  14. modifier 78 present → 70% of the running amount
  15. modifier 80 present → 16% of the running amount
  16. modifier 81 present → 16% of the running amount
  17. modifier 82 present → 16% of the running amount
  18. modifier AS present → 14% of the running amount
  19. modifier QY present → 50% of the running amount
  20. modifier QK present → 50% of the running amount
  21. modifier QX present → 50% of the running amount
  22. cap each charge and the account total at 100% of billed charges
Ohio-Aetna-Medicare-Profee6 base · 21 adj
Aetna Medicare
Profee · CVP_MIDWEST, NOVUS, RS_OHIO · 2023-01-01 → 2999-12-31
Base terms — first match wins
  1. flat $0 — when NoncoverageStatus Noncovered is present
  2. 100% of Medicare drug
  3. 102% of Medicare lab
  4. 102% of Medicare DME
  5. 102% of Medicare RVU
  6. 0% of billed charges
Adjustments — all apply, in order
  1. Medicare multiple-endoscopy reduction
  2. Medicare multiple-ophthalmology reduction — base codes 7; pays 100/80%
  3. Medicare multiple-radiology reduction — base codes 4
  4. Medicare bilateral-surgery adjustment — when Modifier LT is absent; Modifier RT is absent
  5. Medicare multiple-procedure reduction — base codes 2, 3; pays 100/50/25% — when Modifier 55 is absent; Modifier 82 is absent
  6. mid-level provider reduction (by NUCC taxonomy)
  7. modifier 22 present → 135% of the running amount
  8. modifier 52 present → 50% of the running amount
  9. custom SQL — Same global-surgery post-op allocation as hash c5fd5754fcf4a52d (Allowed/GlobalDays*PostOpRate), but hardened: falls back to returning {Allowed} unchanged when GLOB_DAYS or POST_OP is missing/non-numeric/zero instead of dividing by zero. — when Modifier 55 is present
  10. modifier 54 present → 80% of the running amount
  11. modifier 62 present → 62.5% of the running amount
  12. modifier 73 present → 50% of the running amount
  13. modifier 78 present → 70% of the running amount
  14. modifier 80 present → 16% of the running amount
  15. modifier 81 present → 16% of the running amount
  16. modifier 82 present → 16% of the running amount
  17. modifier AS present → 14% of the running amount
  18. modifier QY present → 50% of the running amount
  19. modifier QK present → 50% of the running amount
  20. modifier QX present → 50% of the running amount
  21. cap each charge and the account total at 100% of billed charges
Ohio-Anthem Commercial Facility Fees3 base · 21 adj
Anthem Commercial Plans, Anthem HMO, Anthem PPO
Facility · CVP_MIDWEST, NOVUS, RS_OHIO · 2023-01-01 → 2999-12-31
Base terms — first match wins
  1. flat $0 — when NoncoverageStatus Noncovered is present
  2. case rate from CaseRate (All-level codes)
  3. 70% of billed charges
Adjustments — all apply, in order
  1. Medicare multiple-procedure reduction — base codes 2, 3; pays 100/50% — when Modifier 55 is absent
  2. Medicare multiple-ophthalmology reduction — base codes 7; pays 100/80%
  3. Medicare multiple-endoscopy reduction
  4. Medicare multiple-radiology reduction — base codes 4
  5. Medicare bilateral-surgery adjustment
  6. mid-level provider reduction (by NUCC taxonomy)
  7. modifier 22 present → 135% of the running amount
  8. modifier 52 present → 50% of the running amount
  9. custom SQL — Same global-surgery post-op allocation as hash c5fd5754fcf4a52d (Allowed/GlobalDays*PostOpRate), but hardened: falls back to returning {Allowed} unchanged when GLOB_DAYS or POST_OP is missing/non-numeric/zero instead of dividing by zero. — when Modifier 55 is present
  10. modifier 54 present → 80% of the running amount
  11. modifier 62 present → 62.5% of the running amount
  12. modifier 73 present → 50% of the running amount
  13. modifier 78 present → 70% of the running amount
  14. modifier 80 present → 16% of the running amount
  15. modifier 81 present → 16% of the running amount
  16. modifier 82 present → 16% of the running amount
  17. modifier AS present → 14% of the running amount
  18. modifier QY present → 50% of the running amount
  19. modifier QK present → 50% of the running amount
  20. modifier QX present → 50% of the running amount
  21. cap each charge and the account total at 100% of billed charges
Ohio-Anthem-Cincinnati-Commercial Profees6 base · 21 adj
Anthem Commercial Plans, Anthem HMO, Anthem PPO
Profee · 58 named facilities · 2023-01-01 → 2999-12-31
Base terms — first match wins
  1. flat $0 — when NoncoverageStatus Noncovered is present
  2. 100% of Medicare drug
  3. 100% of the Ohio-Anthem-Cincinnati-Profee-Clinic fee schedule — when FacilityType in Clinic, Home
  4. 100% of the Ohio-Anthem-Cincinnati-Profee-Hospital fee schedule — when FacilityType in ASC, Hospital
  5. 100% of the Ohio-Anthem-Fixed-Fees-Clinic fee schedule — when FacilityType in Clinic, Home
  6. 100% of the Ohio-Anthem-Fixed-Fees-Hospital fee schedule — when FacilityType in ASC, Hospital
Adjustments — all apply, in order
  1. Medicare multiple-procedure reduction — base codes 2, 3; pays 100/50% — when Modifier 55 is absent; Modifier 82 is absent
  2. Medicare multiple-ophthalmology reduction — base codes 7; pays 100/80%
  3. Medicare multiple-endoscopy reduction
  4. Medicare multiple-radiology reduction — base codes 4
  5. Medicare bilateral-surgery adjustment
  6. mid-level provider reduction (by NUCC taxonomy)
  7. modifier 22 present → 135% of the running amount
  8. modifier 52 present → 50% of the running amount
  9. custom SQL — Same global-surgery post-op allocation as hash c5fd5754fcf4a52d (Allowed/GlobalDays*PostOpRate), but hardened: falls back to returning {Allowed} unchanged when GLOB_DAYS or POST_OP is missing/non-numeric/zero instead of dividing by zero. — when Modifier 55 is present
  10. modifier 54 present → 80% of the running amount
  11. modifier 62 present → 62.5% of the running amount
  12. modifier 73 present → 50% of the running amount
  13. modifier 78 present → 70% of the running amount
  14. modifier 80 present → 16% of the running amount
  15. modifier 81 present → 16% of the running amount
  16. modifier 82 present → 16% of the running amount
  17. modifier AS present → 14% of the running amount
  18. modifier QY present → 50% of the running amount
  19. modifier QK present → 50% of the running amount
  20. modifier QX present → 50% of the running amount
  21. cap each charge and the account total at 100% of billed charges
Ohio-Anthem-Cincinnati-Commercial Profees6 base · 21 adj
Anthem Commercial Plans, Anthem HMO, Anthem PPO
Profee · 46 named facilities · 2023-01-01 → 2999-12-31
Base terms — first match wins
  1. flat $0 — when NoncoverageStatus Noncovered is present
  2. 100% of Medicare drug
  3. 100% of the Ohio-Anthem-Dayton-Profee-Clinic fee schedule — when FacilityType in Clinic, Home
  4. 100% of the Ohio-Anthem-Dayton-Profee-Hospital fee schedule — when FacilityType in ASC, Hospital
  5. 100% of the Ohio-Anthem-Fixed-Fees-Clinic fee schedule — when FacilityType in Clinic, Home
  6. 100% of the Ohio-Anthem-Fixed-Fees-Hospital fee schedule — when FacilityType in ASC, Hospital
Adjustments — all apply, in order
  1. Medicare multiple-procedure reduction — base codes 2, 3; pays 100/50% — when Modifier 55 is absent; Modifier 82 is absent
  2. Medicare multiple-ophthalmology reduction — base codes 7; pays 100/80%
  3. Medicare multiple-endoscopy reduction
  4. Medicare multiple-radiology reduction — base codes 4
  5. Medicare bilateral-surgery adjustment
  6. mid-level provider reduction (by NUCC taxonomy)
  7. modifier 22 present → 135% of the running amount
  8. modifier 52 present → 50% of the running amount
  9. custom SQL — Same global-surgery post-op allocation as hash c5fd5754fcf4a52d (Allowed/GlobalDays*PostOpRate), but hardened: falls back to returning {Allowed} unchanged when GLOB_DAYS or POST_OP is missing/non-numeric/zero instead of dividing by zero. — when Modifier 55 is present
  10. modifier 54 present → 80% of the running amount
  11. modifier 62 present → 62.5% of the running amount
  12. modifier 73 present → 50% of the running amount
  13. modifier 78 present → 70% of the running amount
  14. modifier 80 present → 16% of the running amount
  15. modifier 81 present → 16% of the running amount
  16. modifier 82 present → 16% of the running amount
  17. modifier AS present → 14% of the running amount
  18. modifier QY present → 50% of the running amount
  19. modifier QK present → 50% of the running amount
  20. modifier QX present → 50% of the running amount
  21. cap each charge and the account total at 100% of billed charges
Ohio-Anthem-Toledo-Commercial Profees6 base · 21 adj
Anthem Commercial Plans, Anthem HMO, Anthem PPO
Profee · 7 named facilities · 2023-01-01 → 2024-12-31
Base terms — first match wins
  1. flat $0 — when NoncoverageStatus Noncovered is present
  2. 100% of Medicare drug
  3. 115% of the Ohio-Anthem-Toledo-Profee-Clinic fee schedule — when FacilityType in Clinic, Home
  4. 115% of the Ohio-Anthem-Toledo-Profee-Hospital fee schedule — when FacilityType in ASC, Hospital
  5. 100% of the Ohio-Anthem-Fixed-Fees-Clinic fee schedule — when FacilityType in Clinic, Home
  6. 100% of the Ohio-Anthem-Fixed-Fees-Hospital fee schedule — when FacilityType in ASC, Hospital
Adjustments — all apply, in order
  1. Medicare multiple-procedure reduction — base codes 2, 3; pays 100/50% — when Modifier 55 is absent; Modifier 82 is absent
  2. Medicare multiple-ophthalmology reduction — base codes 7; pays 100/80%
  3. Medicare multiple-endoscopy reduction
  4. Medicare multiple-radiology reduction — base codes 4
  5. Medicare bilateral-surgery adjustment
  6. mid-level provider reduction (by NUCC taxonomy)
  7. modifier 22 present → 135% of the running amount
  8. modifier 52 present → 50% of the running amount
  9. custom SQL — Same global-surgery post-op allocation as hash c5fd5754fcf4a52d (Allowed/GlobalDays*PostOpRate), but hardened: falls back to returning {Allowed} unchanged when GLOB_DAYS or POST_OP is missing/non-numeric/zero instead of dividing by zero. — when Modifier 55 is present
  10. modifier 54 present → 80% of the running amount
  11. modifier 62 present → 62.5% of the running amount
  12. modifier 73 present → 50% of the running amount
  13. modifier 78 present → 70% of the running amount
  14. modifier 80 present → 16% of the running amount
  15. modifier 81 present → 16% of the running amount
  16. modifier 82 present → 16% of the running amount
  17. modifier AS present → 14% of the running amount
  18. modifier QY present → 50% of the running amount
  19. modifier QK present → 50% of the running amount
  20. modifier QX present → 50% of the running amount
  21. cap each charge and the account total at 100% of billed charges
Ohio-Anthem-Toledo-Commercial Profees 2025 6 base · 21 adj
Anthem Commercial Plans, Anthem HMO, Anthem PPO
Profee · 7 named facilities · 2025-01-01 → 2025-12-31
Base terms — first match wins
  1. flat $0 — when NoncoverageStatus Noncovered is present
  2. 100% of Medicare drug
  3. 111% of the Ohio-Anthem-Toledo-Profee-Clinic fee schedule — when FacilityType in Clinic, Home
  4. 111% of the Ohio-Anthem-Toledo-Profee-Hospital fee schedule — when FacilityType in ASC, Hospital
  5. 100% of the Ohio-Anthem-Fixed-Fees-Clinic fee schedule — when FacilityType in Clinic, Home
  6. 100% of the Ohio-Anthem-Fixed-Fees-Hospital fee schedule — when FacilityType in ASC, Hospital
Adjustments — all apply, in order
  1. Medicare multiple-procedure reduction — base codes 2, 3; pays 100/50% — when Modifier 55 is absent; Modifier 82 is absent
  2. Medicare multiple-ophthalmology reduction — base codes 7; pays 100/80%
  3. Medicare multiple-endoscopy reduction
  4. Medicare multiple-radiology reduction — base codes 4
  5. Medicare bilateral-surgery adjustment
  6. mid-level provider reduction (by NUCC taxonomy)
  7. modifier 22 present → 135% of the running amount
  8. modifier 52 present → 50% of the running amount
  9. custom SQL — Same global-surgery post-op allocation as hash c5fd5754fcf4a52d (Allowed/GlobalDays*PostOpRate), but hardened: falls back to returning {Allowed} unchanged when GLOB_DAYS or POST_OP is missing/non-numeric/zero instead of dividing by zero. — when Modifier 55 is present
  10. modifier 54 present → 80% of the running amount
  11. modifier 62 present → 62.5% of the running amount
  12. modifier 73 present → 50% of the running amount
  13. modifier 78 present → 70% of the running amount
  14. modifier 80 present → 16% of the running amount
  15. modifier 81 present → 16% of the running amount
  16. modifier 82 present → 16% of the running amount
  17. modifier AS present → 14% of the running amount
  18. modifier QY present → 50% of the running amount
  19. modifier QK present → 50% of the running amount
  20. modifier QX present → 50% of the running amount
  21. cap each charge and the account total at 100% of billed charges
Ohio-Anthem-Toledo-Commercial Profees 20266 base · 21 adj
Anthem Commercial Plans, Anthem HMO, Anthem PPO
Profee · 7 named facilities · 2026-01-01 → 2999-12-31
Base terms — first match wins
  1. flat $0 — when NoncoverageStatus Noncovered is present
  2. 100% of Medicare drug
  3. 113% of the Ohio-Anthem-Toledo-Profee-Clinic fee schedule — when FacilityType in Clinic, Home
  4. 113% of the Ohio-Anthem-Toledo-Profee-Hospital fee schedule — when FacilityType in ASC, Hospital
  5. 100% of the Ohio-Anthem-Fixed-Fees-Clinic fee schedule — when FacilityType in Clinic, Home
  6. 100% of the Ohio-Anthem-Fixed-Fees-Hospital fee schedule — when FacilityType in ASC, Hospital
Adjustments — all apply, in order
  1. Medicare multiple-procedure reduction — base codes 2, 3; pays 100/50% — when Modifier 55 is absent; Modifier 82 is absent
  2. Medicare multiple-ophthalmology reduction — base codes 7; pays 100/80%
  3. Medicare multiple-endoscopy reduction
  4. Medicare multiple-radiology reduction — base codes 4
  5. Medicare bilateral-surgery adjustment
  6. mid-level provider reduction (by NUCC taxonomy)
  7. modifier 22 present → 135% of the running amount
  8. modifier 52 present → 50% of the running amount
  9. custom SQL — Same global-surgery post-op allocation as hash c5fd5754fcf4a52d (Allowed/GlobalDays*PostOpRate), but hardened: falls back to returning {Allowed} unchanged when GLOB_DAYS or POST_OP is missing/non-numeric/zero instead of dividing by zero. — when Modifier 55 is present
  10. modifier 54 present → 80% of the running amount
  11. modifier 62 present → 62.5% of the running amount
  12. modifier 73 present → 50% of the running amount
  13. modifier 78 present → 70% of the running amount
  14. modifier 80 present → 16% of the running amount
  15. modifier 81 present → 16% of the running amount
  16. modifier 82 present → 16% of the running amount
  17. modifier AS present → 14% of the running amount
  18. modifier QY present → 50% of the running amount
  19. modifier QK present → 50% of the running amount
  20. modifier QX present → 50% of the running amount
  21. cap each charge and the account total at 100% of billed charges
Ohio-Caresource Medicaid Profees6 base · 20 adj
Caresource Medicaid
Profee · CVP_MIDWEST, NOVUS, RS_OHIO, OH · 2023-01-01 → 2999-12-31
Base terms — first match wins
  1. flat $0 — when NoncoverageStatus Noncovered is present
  2. 100% of Medicare drug
  3. 105% of the Fixed-Fees-DME fee schedule
  4. 105% of the Fixed-Fees-Labs fee schedule
  5. 105% of the Profee-Fees fee schedule
  6. 0% of billed charges
Adjustments — all apply, in order
  1. Medicare multiple-procedure reduction — base codes 2, 3; pays 100/50% — when Modifier 55 is absent; Modifier 82 is absent
  2. Medicare multiple-endoscopy reduction
  3. Medicare multiple-radiology reduction — base codes 4
  4. Medicare bilateral-surgery adjustment
  5. mid-level provider reduction (by NUCC taxonomy)
  6. modifier 22 present → 135% of the running amount
  7. modifier 52 present → 50% of the running amount
  8. custom SQL — Same global-surgery post-op allocation as hash c5fd5754fcf4a52d (Allowed/GlobalDays*PostOpRate), but hardened: falls back to returning {Allowed} unchanged when GLOB_DAYS or POST_OP is missing/non-numeric/zero instead of dividing by zero. — when Modifier 55 is present
  9. modifier 54 present → 80% of the running amount
  10. modifier 62 present → 62.5% of the running amount
  11. modifier 73 present → 50% of the running amount
  12. modifier 78 present → 70% of the running amount
  13. modifier 80 present → 16% of the running amount
  14. modifier 81 present → 16% of the running amount
  15. modifier 82 present → 16% of the running amount
  16. modifier AS present → 14% of the running amount
  17. modifier QY present → 50% of the running amount
  18. modifier QK present → 50% of the running amount
  19. modifier QX present → 50% of the running amount
  20. cap each charge and the account total at 100% of billed charges
Ohio-Cigna Faciltiy Fees (9.1.2023)3 base · 21 adj
Cigna
Facility · CVP_MIDWEST, NOVUS, RS_OHIO · 2023-01-01 → 2024-08-31
Base terms — first match wins
  1. flat $0 — when NoncoverageStatus Noncovered is present
  2. 99% of Medicare ASC
  3. flat $0
Adjustments — all apply, in order
  1. multiple-surgery reduction (contract rules) — pays 100/50%
  2. Medicare multiple-procedure reduction — base codes 2; pays 100/50%
  3. Medicare multiple-endoscopy reduction
  4. Medicare multiple-radiology reduction — base codes 4
  5. Medicare bilateral-surgery adjustment
  6. mid-level provider reduction (by NUCC taxonomy)
  7. modifier 22 present → 135% of the running amount
  8. modifier 52 present → 50% of the running amount
  9. custom SQL — Same global-surgery post-op allocation as hash c5fd5754fcf4a52d (Allowed/GlobalDays*PostOpRate), but hardened: falls back to returning {Allowed} unchanged when GLOB_DAYS or POST_OP is missing/non-numeric/zero instead of dividing by zero. — when Modifier 55 is present
  10. modifier 54 present → 80% of the running amount
  11. modifier 62 present → 62.5% of the running amount
  12. modifier 73 present → 50% of the running amount
  13. modifier 78 present → 70% of the running amount
  14. modifier 80 present → 16% of the running amount
  15. modifier 81 present → 16% of the running amount
  16. modifier 82 present → 16% of the running amount
  17. modifier AS present → 14% of the running amount
  18. modifier QY present → 50% of the running amount
  19. modifier QK present → 50% of the running amount
  20. modifier QX present → 50% of the running amount
  21. cap each charge and the account total at 100% of billed charges
Ohio-Cigna Faciltiy Fees (9.1.2024)3 base · 21 adj
Cigna
Facility · CVP_MIDWEST, NOVUS, RS_OHIO · 2024-09-01 → 2025-08-31
Base terms — first match wins
  1. flat $0 — when NoncoverageStatus Noncovered is present
  2. 102% of Medicare ASC
  3. flat $0
Adjustments — all apply, in order
  1. multiple-surgery reduction (contract rules) — pays 100/50%
  2. Medicare multiple-procedure reduction — base codes 2; pays 100/50%
  3. Medicare multiple-endoscopy reduction
  4. Medicare multiple-radiology reduction — base codes 4
  5. Medicare bilateral-surgery adjustment
  6. mid-level provider reduction (by NUCC taxonomy)
  7. modifier 22 present → 135% of the running amount
  8. modifier 52 present → 50% of the running amount
  9. custom SQL — Same global-surgery post-op allocation as hash c5fd5754fcf4a52d (Allowed/GlobalDays*PostOpRate), but hardened: falls back to returning {Allowed} unchanged when GLOB_DAYS or POST_OP is missing/non-numeric/zero instead of dividing by zero. — when Modifier 55 is present
  10. modifier 54 present → 80% of the running amount
  11. modifier 62 present → 62.5% of the running amount
  12. modifier 73 present → 50% of the running amount
  13. modifier 78 present → 70% of the running amount
  14. modifier 80 present → 16% of the running amount
  15. modifier 81 present → 16% of the running amount
  16. modifier 82 present → 16% of the running amount
  17. modifier AS present → 14% of the running amount
  18. modifier QY present → 50% of the running amount
  19. modifier QK present → 50% of the running amount
  20. modifier QX present → 50% of the running amount
  21. cap each charge and the account total at 100% of billed charges
Ohio-Cigna Faciltiy Fees (9.1.2025)3 base · 21 adj
Cigna
Facility · CVP_MIDWEST, NOVUS, RS_OHIO · 2025-09-01 → 2999-12-31
Base terms — first match wins
  1. flat $0 — when NoncoverageStatus Noncovered is present
  2. 105% of Medicare ASC
  3. flat $0
Adjustments — all apply, in order
  1. multiple-surgery reduction (contract rules) — pays 100/50%
  2. Medicare multiple-procedure reduction — base codes 2; pays 100/50%
  3. Medicare multiple-endoscopy reduction
  4. Medicare multiple-radiology reduction — base codes 4
  5. Medicare bilateral-surgery adjustment
  6. mid-level provider reduction (by NUCC taxonomy)
  7. modifier 22 present → 135% of the running amount
  8. modifier 52 present → 50% of the running amount
  9. custom SQL — Same global-surgery post-op allocation as hash c5fd5754fcf4a52d (Allowed/GlobalDays*PostOpRate), but hardened: falls back to returning {Allowed} unchanged when GLOB_DAYS or POST_OP is missing/non-numeric/zero instead of dividing by zero. — when Modifier 55 is present
  10. modifier 54 present → 80% of the running amount
  11. modifier 62 present → 62.5% of the running amount
  12. modifier 73 present → 50% of the running amount
  13. modifier 78 present → 70% of the running amount
  14. modifier 80 present → 16% of the running amount
  15. modifier 81 present → 16% of the running amount
  16. modifier 82 present → 16% of the running amount
  17. modifier AS present → 14% of the running amount
  18. modifier QY present → 50% of the running amount
  19. modifier QK present → 50% of the running amount
  20. modifier QX present → 50% of the running amount
  21. cap each charge and the account total at 100% of billed charges
Ohio-Cigna-Profee3 base · 20 adj
Cigna
Profee · CVP_MIDWEST, NOVUS, RS_OHIO · 2023-01-01 → 2999-12-31
Base terms — first match wins
  1. flat $0 — when NoncoverageStatus Noncovered is present
  2. 100% of the Profee-Fees fee schedule
  3. 100% of the Profee-Drug fee schedule
Adjustments — all apply, in order
  1. Medicare multiple-procedure reduction — base codes 2, 3; pays 100/50% — when Modifier 55 is absent; Modifier 82 is absent
  2. Medicare multiple-endoscopy reduction
  3. Medicare multiple-radiology reduction — base codes 4
  4. Medicare bilateral-surgery adjustment
  5. mid-level provider reduction (by NUCC taxonomy)
  6. modifier 22 present → 135% of the running amount
  7. modifier 52 present → 50% of the running amount
  8. custom SQL — Same global-surgery post-op allocation as hash c5fd5754fcf4a52d (Allowed/GlobalDays*PostOpRate), but hardened: falls back to returning {Allowed} unchanged when GLOB_DAYS or POST_OP is missing/non-numeric/zero instead of dividing by zero. — when Modifier 55 is present
  9. modifier 54 present → 80% of the running amount
  10. modifier 62 present → 62.5% of the running amount
  11. modifier 73 present → 50% of the running amount
  12. modifier 78 present → 70% of the running amount
  13. modifier 80 present → 16% of the running amount
  14. modifier 81 present → 16% of the running amount
  15. modifier 82 present → 16% of the running amount
  16. modifier AS present → 14% of the running amount
  17. modifier QY present → 50% of the running amount
  18. modifier QK present → 50% of the running amount
  19. modifier QX present → 50% of the running amount
  20. cap each charge and the account total at 100% of billed charges
Ohio-DevotedMedicare-Profee6 base · 20 adj
Devoted Medicare
Profee · CVP_MIDWEST, NOVUS, RS_OHIO · 2023-01-01 → 2999-12-31
Base terms — first match wins
  1. flat $0 — when NoncoverageStatus Noncovered is present
  2. 104% of Medicare lab
  3. 100% of Medicare drug
  4. 104% of Medicare DME
  5. 104% of Medicare RVU
  6. 0% of billed charges
Adjustments — all apply, in order
  1. Medicare multiple-procedure reduction — base codes 2, 3; pays 100/50% — when Modifier 55 is absent; Modifier 82 is absent
  2. Medicare multiple-endoscopy reduction
  3. Medicare multiple-radiology reduction — base codes 4
  4. Medicare bilateral-surgery adjustment
  5. mid-level provider reduction (by NUCC taxonomy)
  6. modifier 22 present → 135% of the running amount
  7. modifier 52 present → 50% of the running amount
  8. custom SQL — Same global-surgery post-op allocation as hash c5fd5754fcf4a52d (Allowed/GlobalDays*PostOpRate), but hardened: falls back to returning {Allowed} unchanged when GLOB_DAYS or POST_OP is missing/non-numeric/zero instead of dividing by zero. — when Modifier 55 is present
  9. modifier 54 present → 80% of the running amount
  10. modifier 62 present → 62.5% of the running amount
  11. modifier 73 present → 50% of the running amount
  12. modifier 78 present → 70% of the running amount
  13. modifier 80 present → 16% of the running amount
  14. modifier 81 present → 16% of the running amount
  15. modifier 82 present → 16% of the running amount
  16. modifier AS present → 14% of the running amount
  17. modifier QY present → 50% of the running amount
  18. modifier QK present → 50% of the running amount
  19. modifier QX present → 50% of the running amount
  20. cap each charge and the account total at 100% of billed charges
Ohio-FirstHealth-Profee6 base · 20 adj
First Health
Profee · CVP_MIDWEST, NOVUS, RS_OHIO · 2023-01-01 → 2999-12-31
Base terms — first match wins
  1. flat $0 — when NoncoverageStatus Noncovered is present
  2. 134% of the Fixed-Fees-Drugs fee schedule
  3. 175% of Medicare lab
  4. 175% of Medicare DME ⚠︎ named “100% of Medicare DME” but configured at 175%
  5. 175% of Medicare RVU
  6. 0% of billed charges
Adjustments — all apply, in order
  1. Medicare multiple-procedure reduction — base codes 2, 3; pays 100/50% — when Modifier 55 is absent; Modifier 82 is absent
  2. Medicare multiple-endoscopy reduction
  3. Medicare multiple-radiology reduction — base codes 4
  4. Medicare bilateral-surgery adjustment
  5. mid-level provider reduction (by NUCC taxonomy)
  6. modifier 22 present → 135% of the running amount
  7. modifier 52 present → 50% of the running amount
  8. custom SQL — Same global-surgery post-op allocation as hash c5fd5754fcf4a52d (Allowed/GlobalDays*PostOpRate), but hardened: falls back to returning {Allowed} unchanged when GLOB_DAYS or POST_OP is missing/non-numeric/zero instead of dividing by zero. — when Modifier 55 is present
  9. modifier 54 present → 80% of the running amount
  10. modifier 62 present → 62.5% of the running amount
  11. modifier 73 present → 50% of the running amount
  12. modifier 78 present → 70% of the running amount
  13. modifier 80 present → 16% of the running amount
  14. modifier 81 present → 16% of the running amount
  15. modifier 82 present → 16% of the running amount
  16. modifier AS present → 14% of the running amount
  17. modifier QY present → 50% of the running amount
  18. modifier QK present → 50% of the running amount
  19. modifier QX present → 50% of the running amount
  20. cap each charge and the account total at 100% of billed charges
Ohio-KYHealthAdministrators-Profee1 base · 20 adj
KY Health Administrators
Profee · CVP_MIDWEST, NOVUS, RS_OHIO · 2023-01-01 → 2999-12-31
Base terms — first match wins
  1. 80% of billed charges
Adjustments — all apply, in order
  1. Medicare multiple-endoscopy reduction
  2. Medicare multiple-radiology reduction — base codes 4
  3. Medicare bilateral-surgery adjustment
  4. Medicare multiple-procedure reduction — base codes 2, 3; pays 100/50% — when Modifier 55 is absent; Modifier 82 is absent
  5. mid-level provider reduction (by NUCC taxonomy)
  6. modifier 22 present → 135% of the running amount
  7. modifier 52 present → 50% of the running amount
  8. modifier 54 present → 80% of the running amount
  9. custom SQL — Same global-surgery post-op allocation as hash c5fd5754fcf4a52d (Allowed/GlobalDays*PostOpRate), but hardened: falls back to returning {Allowed} unchanged when GLOB_DAYS or POST_OP is missing/non-numeric/zero instead of dividing by zero. — when Modifier 55 is present
  10. modifier 62 present → 62.5% of the running amount
  11. modifier 73 present → 50% of the running amount
  12. modifier 78 present → 70% of the running amount
  13. modifier 80 present → 16% of the running amount
  14. modifier 81 present → 16% of the running amount
  15. modifier 82 present → 16% of the running amount
  16. modifier AS present → 14% of the running amount
  17. modifier QY present → 50% of the running amount
  18. modifier QK present → 50% of the running amount
  19. modifier QX present → 50% of the running amount
  20. cap each charge and the account total at 100% of billed charges
Ohio-MedBenAdministrators-Profee7 base · 20 adj
Med Ben Administrators
Profee · CVP_MIDWEST, NOVUS, RS_OHIO · 2023-01-01 → 2999-12-31
Base terms — first match wins
  1. flat $0 — when NoncoverageStatus Noncovered is present
  2. 100% of the Carveouts fee schedule
  3. 175% of Medicare lab
  4. 100% of Medicare drug
  5. 175% of Medicare DME
  6. 175% of Medicare RVU
  7. 0% of billed charges
Adjustments — all apply, in order
  1. Medicare multiple-procedure reduction — base codes 2, 3; pays 100/50% — when Modifier 55 is absent; Modifier 82 is absent
  2. Medicare multiple-endoscopy reduction
  3. Medicare multiple-radiology reduction — base codes 4
  4. Medicare bilateral-surgery adjustment
  5. mid-level provider reduction (by NUCC taxonomy)
  6. modifier 22 present → 135% of the running amount
  7. modifier 52 present → 50% of the running amount
  8. custom SQL — Same global-surgery post-op allocation as hash c5fd5754fcf4a52d (Allowed/GlobalDays*PostOpRate), but hardened: falls back to returning {Allowed} unchanged when GLOB_DAYS or POST_OP is missing/non-numeric/zero instead of dividing by zero. — when Modifier 55 is present
  9. modifier 54 present → 80% of the running amount
  10. modifier 62 present → 62.5% of the running amount
  11. modifier 73 present → 50% of the running amount
  12. modifier 78 present → 70% of the running amount
  13. modifier 80 present → 16% of the running amount
  14. modifier 81 present → 16% of the running amount
  15. modifier 82 present → 16% of the running amount
  16. modifier AS present → 14% of the running amount
  17. modifier QY present → 50% of the running amount
  18. modifier QK present → 50% of the running amount
  19. modifier QX present → 50% of the running amount
  20. cap each charge and the account total at 100% of billed charges
Ohio-OHHealthChoice-Profee7 base · 20 adj
OH Health Choice
Profee · CVP_MIDWEST, NOVUS, RS_OHIO · 2023-01-01 → 2999-12-31
Base terms — first match wins
  1. flat $0 — when NoncoverageStatus Noncovered is present
  2. 170% of Medicare RVU — when OHHealthChoiceCarveoutCodes 170 is present
  3. 135% of Medicare lab
  4. 100% of Medicare drug
  5. 135% of Medicare DME
  6. 135% of Medicare RVU
  7. 70% of billed charges
Adjustments — all apply, in order
  1. Medicare multiple-procedure reduction — base codes 2, 3; pays 100/50% — when Modifier 55 is absent; Modifier 82 is absent
  2. Medicare multiple-endoscopy reduction
  3. Medicare multiple-radiology reduction — base codes 4
  4. Medicare bilateral-surgery adjustment
  5. mid-level provider reduction (by NUCC taxonomy)
  6. modifier 22 present → 135% of the running amount
  7. modifier 52 present → 50% of the running amount
  8. custom SQL — Same global-surgery post-op allocation as hash c5fd5754fcf4a52d (Allowed/GlobalDays*PostOpRate), but hardened: falls back to returning {Allowed} unchanged when GLOB_DAYS or POST_OP is missing/non-numeric/zero instead of dividing by zero. — when Modifier 55 is present
  9. modifier 54 present → 80% of the running amount
  10. modifier 62 present → 62.5% of the running amount
  11. modifier 73 present → 50% of the running amount
  12. modifier 78 present → 70% of the running amount
  13. modifier 80 present → 16% of the running amount
  14. modifier 81 present → 16% of the running amount
  15. modifier 82 present → 16% of the running amount
  16. modifier AS present → 14% of the running amount
  17. modifier QY present → 50% of the running amount
  18. modifier QK present → 50% of the running amount
  19. modifier QX present → 50% of the running amount
  20. cap each charge and the account total at 100% of billed charges
Ohio-PerennialAdvantage-Profee8 base · 20 adj
Perennial Advantage
Profee · CVP_MIDWEST, NOVUS, RS_OHIO · 2023-01-01 → 2999-12-31
Base terms — first match wins
  1. flat $0 — when NoncoverageStatus Noncovered is present
  2. flat $1000 — when ProcedureCode J3490 is present
  3. flat $1000 — when ProcedureCode J3590 is present
  4. 105% of Medicare lab
  5. 100% of Medicare drug
  6. 105% of Medicare DME
  7. 105% of Medicare RVU
  8. 0% of billed charges
Adjustments — all apply, in order
  1. Medicare multiple-procedure reduction — base codes 2, 3; pays 100/50% — when Modifier 55 is absent; Modifier 82 is absent
  2. Medicare multiple-endoscopy reduction
  3. Medicare multiple-radiology reduction — base codes 4
  4. Medicare bilateral-surgery adjustment
  5. mid-level provider reduction (by NUCC taxonomy)
  6. modifier 22 present → 135% of the running amount
  7. modifier 52 present → 50% of the running amount
  8. custom SQL — Same global-surgery post-op allocation as hash c5fd5754fcf4a52d (Allowed/GlobalDays*PostOpRate), but hardened: falls back to returning {Allowed} unchanged when GLOB_DAYS or POST_OP is missing/non-numeric/zero instead of dividing by zero. — when Modifier 55 is present
  9. modifier 54 present → 80% of the running amount
  10. modifier 62 present → 62.5% of the running amount
  11. modifier 73 present → 50% of the running amount
  12. modifier 78 present → 70% of the running amount
  13. modifier 80 present → 16% of the running amount
  14. modifier 81 present → 16% of the running amount
  15. modifier 82 present → 16% of the running amount
  16. modifier AS present → 14% of the running amount
  17. modifier QY present → 50% of the running amount
  18. modifier QK present → 50% of the running amount
  19. modifier QX present → 50% of the running amount
  20. cap each charge and the account total at 100% of billed charges
Ohio-Tricare-Profee3 base · 20 adj
Tricare
Profee · CVP_MIDWEST, NOVUS, RS_OHIO · 2023-01-01 → 2999-12-31
Base terms — first match wins
  1. flat $0 — when NoncoverageStatus Noncovered is present
  2. 100% of Medicare drug
  3. 100% of the Profee-Fees fee schedule
Adjustments — all apply, in order
  1. Medicare multiple-procedure reduction — base codes 2, 3; pays 100/50% — when Modifier 55 is absent; Modifier 82 is absent
  2. Medicare multiple-endoscopy reduction
  3. Medicare multiple-radiology reduction — base codes 4
  4. Medicare bilateral-surgery adjustment
  5. mid-level provider reduction (by NUCC taxonomy)
  6. modifier 22 present → 135% of the running amount
  7. modifier 52 present → 50% of the running amount
  8. custom SQL — Same global-surgery post-op allocation as hash c5fd5754fcf4a52d (Allowed/GlobalDays*PostOpRate), but hardened: falls back to returning {Allowed} unchanged when GLOB_DAYS or POST_OP is missing/non-numeric/zero instead of dividing by zero. — when Modifier 55 is present
  9. modifier 54 present → 80% of the running amount
  10. modifier 62 present → 62.5% of the running amount
  11. modifier 73 present → 50% of the running amount
  12. modifier 78 present → 70% of the running amount
  13. modifier 80 present → 16% of the running amount
  14. modifier 81 present → 16% of the running amount
  15. modifier 82 present → 16% of the running amount
  16. modifier AS present → 14% of the running amount
  17. modifier QY present → 50% of the running amount
  18. modifier QK present → 50% of the running amount
  19. modifier QX present → 50% of the running amount
  20. cap each charge and the account total at 100% of billed charges
Ohio-UHC-Medicare-Profee3 base · 21 adj
United Healthcare Medicare
Profee · CVP_MIDWEST, NOVUS, RS_OHIO · 2023-01-01 → 2023-12-31
Base terms — first match wins
  1. flat $0 — when NoncoverageStatus Noncovered is present
  2. 100% of Medicare drug
  3. 100% of the Profee-Fees fee schedule
Adjustments — all apply, in order
  1. Medicare multiple-procedure reduction — base codes 2, 3; pays 100/50% — when Modifier 55 is absent; Modifier 82 is absent
  2. Medicare multiple-endoscopy reduction
  3. Medicare multiple-radiology reduction — base codes 4
  4. Medicare bilateral-surgery adjustment
  5. mid-level provider reduction (by NUCC taxonomy)
  6. modifier 22 present → 135% of the running amount
  7. modifier 52 present → 50% of the running amount
  8. modifier 53 present → 25% of the running amount
  9. custom SQL — Same global-surgery post-op allocation as hash c5fd5754fcf4a52d (Allowed/GlobalDays*PostOpRate), but hardened: falls back to returning {Allowed} unchanged when GLOB_DAYS or POST_OP is missing/non-numeric/zero instead of dividing by zero. — when Modifier 55 is present
  10. modifier 54 present → 80% of the running amount
  11. modifier 62 present → 62.5% of the running amount
  12. modifier 73 present → 50% of the running amount
  13. modifier 78 present → 70% of the running amount
  14. modifier 80 present → 16% of the running amount
  15. modifier 81 present → 16% of the running amount
  16. modifier 82 present → 16% of the running amount
  17. modifier AS present → 14% of the running amount
  18. modifier QY present → 50% of the running amount
  19. modifier QK present → 50% of the running amount
  20. modifier QX present → 50% of the running amount
  21. cap each charge and the account total at 100% of billed charges
Ohio-UHC-Profee3 base · 22 adj
United Healthcare
Profee · CVP_MIDWEST, NOVUS, RS_OHIO · 2023-01-01 → 2999-12-31
Base terms — first match wins
  1. flat $0 — when NoncoverageStatus Noncovered is present
  2. 100% of Medicare drug
  3. 100% of the Profee-Fees fee schedule
Adjustments — all apply, in order
  1. Medicare multiple-procedure reduction — base codes 2, 3; pays 100/50% — when Modifier 55 is absent; Modifier 82 is absent
  2. Medicare multiple-endoscopy reduction
  3. Medicare multiple-radiology reduction — base codes 4
  4. Medicare bilateral-surgery adjustment
  5. mid-level provider reduction (by NUCC taxonomy)
  6. modifier 22 present → 135% of the running amount
  7. modifier 52 present → 50% of the running amount
  8. modifier 53 present → 25% of the running amount
  9. custom SQL — Same global-surgery post-op allocation as hash c5fd5754fcf4a52d (Allowed/GlobalDays*PostOpRate), but hardened: falls back to returning {Allowed} unchanged when GLOB_DAYS or POST_OP is missing/non-numeric/zero instead of dividing by zero. — when Modifier 55 is present
  10. modifier 54 present → 80% of the running amount
  11. modifier 62 present → 62.5% of the running amount
  12. modifier 73 present → 50% of the running amount
  13. modifier 78 present → 70% of the running amount
  14. modifier 80 present → 16% of the running amount
  15. modifier 81 present → 16% of the running amount
  16. modifier 82 present → 16% of the running amount
  17. modifier AS present → 14% of the running amount
  18. modifier QY present → 50% of the running amount
  19. modifier QK present → 50% of the running amount
  20. modifier QX present → 50% of the running amount
  21. modifier QZ present → 85% of the running amount
  22. cap each charge and the account total at 100% of billed charges
Panhandle-Cigna Healthsprings Profees10 base · 20 adj
Cigna Medicare
Profee · PANHANDLE · 2023-01-01 → 2999-12-31
Base terms — first match wins
  1. flat $0 — when NoncoverageStatus Noncovered is present
  2. flat $100 — when ProcedureCode 92002 is present
  3. flat $100 — when ProcedureCode 92004 is present
  4. flat $100 — when ProcedureCode 92012 is present
  5. flat $100 — when ProcedureCode 92014 is present
  6. 100% of Medicare lab
  7. 100% of Medicare drug
  8. 100% of Medicare DME
  9. 100% of Medicare RVU
  10. 0% of billed charges
Adjustments — all apply, in order
  1. Medicare multiple-procedure reduction — base codes 2, 3; pays 100/50% — when Modifier 55 is absent; Modifier 82 is absent
  2. Medicare multiple-endoscopy reduction
  3. Medicare multiple-radiology reduction — base codes 4
  4. Medicare bilateral-surgery adjustment
  5. mid-level provider reduction (by NUCC taxonomy)
  6. modifier 22 present → 135% of the running amount
  7. modifier 52 present → 50% of the running amount
  8. custom SQL — Same global-surgery post-op allocation as hash c5fd5754fcf4a52d (Allowed/GlobalDays*PostOpRate), but hardened: falls back to returning {Allowed} unchanged when GLOB_DAYS or POST_OP is missing/non-numeric/zero instead of dividing by zero. — when Modifier 55 is present
  9. modifier 54 present → 80% of the running amount
  10. modifier 62 present → 62.5% of the running amount
  11. modifier 73 present → 50% of the running amount
  12. modifier 78 present → 70% of the running amount
  13. modifier 80 present → 16% of the running amount
  14. modifier 81 present → 16% of the running amount
  15. modifier 82 present → 16% of the running amount
  16. modifier AS present → 14% of the running amount
  17. modifier QY present → 50% of the running amount
  18. modifier QK present → 50% of the running amount
  19. modifier QX present → 50% of the running amount
  20. cap each charge and the account total at 100% of billed charges
Pinellas-Aetna Profees4 base · 21 adj
Aetna
Profee · EIWF, ASC, Clinic, Home, Hospital · 2023-01-01 → 2999-12-31
Base terms — first match wins
  1. flat $0 — when NoncoverageStatus Noncovered is present
  2. 100% of Medicare drug
  3. 100% of the Pinellas-Aetna-Profee-Fees fee schedule — when FacilityType in Clinic
  4. 100% of the Pinellas-Aetna-Facility-Profee-Fees fee schedule — when FacilityType in ASC, Hospital, Home
Adjustments — all apply, in order
  1. Medicare multiple-procedure reduction — base codes 2, 3; pays 100/50/25% — when Modifier 55 is absent; Modifier 82 is absent
  2. Medicare multiple-ophthalmology reduction — base codes 7; pays 100/80%
  3. Medicare multiple-endoscopy reduction
  4. Medicare multiple-radiology reduction — base codes 4
  5. Medicare bilateral-surgery adjustment
  6. mid-level provider reduction (by NUCC taxonomy)
  7. modifier 22 present → 135% of the running amount
  8. modifier 52 present → 50% of the running amount
  9. custom SQL — Same global-surgery post-op allocation as hash c5fd5754fcf4a52d (Allowed/GlobalDays*PostOpRate), but hardened: falls back to returning {Allowed} unchanged when GLOB_DAYS or POST_OP is missing/non-numeric/zero instead of dividing by zero. — when Modifier 55 is present
  10. modifier 54 present → 80% of the running amount
  11. modifier 62 present → 62.5% of the running amount
  12. modifier 73 present → 50% of the running amount
  13. modifier 78 present → 70% of the running amount
  14. modifier 80 present → 16% of the running amount
  15. modifier 81 present → 16% of the running amount
  16. modifier 82 present → 16% of the running amount
  17. modifier AS present → 14% of the running amount
  18. modifier QY present → 50% of the running amount
  19. modifier QK present → 50% of the running amount
  20. modifier QX present → 50% of the running amount
  21. cap each charge and the account total at 100% of billed charges
Pinellas-Humana Profees4 base · 20 adj
Humana, Humana Medicare
Profee · EIWF, ASC, Clinic, Home, Hospital · 2023-01-01 → 2999-12-31
Base terms — first match wins
  1. flat $0 — when NoncoverageStatus Noncovered is present
  2. 100% of Medicare drug
  3. 100% of the Pinellas-Humana-Profee-Fees fee schedule — when FacilityType in Clinic
  4. 100% of the Pinellas-Humana-Facility-Profee-Fees fee schedule — when FacilityType in ASC, Hospital, Home
Adjustments — all apply, in order
  1. Medicare multiple-procedure reduction — base codes 2, 3; pays 100/50% — when Modifier 55 is absent; Modifier 82 is absent
  2. Medicare multiple-endoscopy reduction
  3. Medicare multiple-radiology reduction — base codes 4
  4. Medicare bilateral-surgery adjustment
  5. mid-level provider reduction (by NUCC taxonomy)
  6. modifier 22 present → 135% of the running amount
  7. modifier 52 present → 50% of the running amount
  8. custom SQL — Same global-surgery post-op allocation as hash c5fd5754fcf4a52d (Allowed/GlobalDays*PostOpRate), but hardened: falls back to returning {Allowed} unchanged when GLOB_DAYS or POST_OP is missing/non-numeric/zero instead of dividing by zero. — when Modifier 55 is present
  9. modifier 54 present → 80% of the running amount
  10. modifier 62 present → 62.5% of the running amount
  11. modifier 73 present → 50% of the running amount
  12. modifier 78 present → 70% of the running amount
  13. modifier 80 present → 16% of the running amount
  14. modifier 81 present → 16% of the running amount
  15. modifier 82 present → 16% of the running amount
  16. modifier AS present → 14% of the running amount
  17. modifier QY present → 50% of the running amount
  18. modifier QK present → 50% of the running amount
  19. modifier QX present → 50% of the running amount
  20. cap each charge and the account total at 100% of billed charges
Pinellas-UHC Profees4 base · 22 adj
United Healthcare, United Healthcare Medicare
Profee · EIWF, ASC, Clinic, Home, Hospital · 2023-01-01 → 2999-12-31
Base terms — first match wins
  1. flat $0 — when NoncoverageStatus Noncovered is present
  2. 100% of Medicare drug
  3. 100% of the Pinellas-UHC-Profee-Fees fee schedule — when FacilityType in Clinic
  4. 100% of the Pinellas-UHC-Facility-Profee-Fees fee schedule — when FacilityType in ASC, Hospital, Home
Adjustments — all apply, in order
  1. Medicare multiple-procedure reduction — base codes 2, 3; pays 100/50% — when Modifier 55 is absent; Modifier 82 is absent
  2. Medicare multiple-endoscopy reduction
  3. Medicare multiple-radiology reduction — base codes 4
  4. Medicare bilateral-surgery adjustment
  5. mid-level provider reduction (by NUCC taxonomy)
  6. modifier 22 present → 135% of the running amount
  7. modifier 52 present → 50% of the running amount
  8. modifier 53 present → 25% of the running amount
  9. custom SQL — Same global-surgery post-op allocation as hash c5fd5754fcf4a52d (Allowed/GlobalDays*PostOpRate), but hardened: falls back to returning {Allowed} unchanged when GLOB_DAYS or POST_OP is missing/non-numeric/zero instead of dividing by zero. — when Modifier 55 is present
  10. modifier 54 present → 80% of the running amount
  11. modifier 62 present → 62.5% of the running amount
  12. modifier 73 present → 50% of the running amount
  13. modifier 78 present → 70% of the running amount
  14. modifier 80 present → 16% of the running amount
  15. modifier 81 present → 16% of the running amount
  16. modifier 82 present → 16% of the running amount
  17. modifier AS present → 14% of the running amount
  18. modifier QY present → 50% of the running amount
  19. modifier QK present → 50% of the running amount
  20. modifier QX present → 50% of the running amount
  21. modifier QZ present → 85% of the running amount
  22. cap each charge and the account total at 100% of billed charges
QVC - Cigna Profees (8.15.23 to 8.14.24)6 base · 20 adj
Cigna
Profee · QUANTUM · 2023-08-15 → 2024-08-14
Cigna
Profee · OPHC_NEXTGEN · 2023-08-15 → 2024-08-14
Base terms — first match wins
  1. flat $0 — when NoncoverageStatus Noncovered is present
  2. 100% of Medicare lab
  3. 100% of Medicare drug
  4. 100% of Medicare DME
  5. 108% of Medicare RVU
  6. 0% of billed charges
Adjustments — all apply, in order
  1. Medicare multiple-procedure reduction — base codes 2, 3; pays 100/50% — when Modifier 55 is absent; Modifier 82 is absent
  2. Medicare multiple-endoscopy reduction
  3. Medicare multiple-radiology reduction — base codes 4
  4. Medicare bilateral-surgery adjustment
  5. mid-level provider reduction (by NUCC taxonomy)
  6. modifier 22 present → 135% of the running amount
  7. modifier 52 present → 50% of the running amount
  8. custom SQL — Same global-surgery post-op allocation as hash c5fd5754fcf4a52d (Allowed/GlobalDays*PostOpRate), but hardened: falls back to returning {Allowed} unchanged when GLOB_DAYS or POST_OP is missing/non-numeric/zero instead of dividing by zero. — when Modifier 55 is present
  9. modifier 54 present → 80% of the running amount
  10. modifier 62 present → 62.5% of the running amount
  11. modifier 73 present → 50% of the running amount
  12. modifier 78 present → 70% of the running amount
  13. modifier 80 present → 16% of the running amount
  14. modifier 81 present → 16% of the running amount
  15. modifier 82 present → 16% of the running amount
  16. modifier AS present → 14% of the running amount
  17. modifier QY present → 50% of the running amount
  18. modifier QK present → 50% of the running amount
  19. modifier QX present → 50% of the running amount
  20. cap each charge and the account total at 100% of billed charges
QVC - Cigna Profees (8.15.24 to 8.14.25)6 base · 20 adj
Cigna
Profee · QUANTUM · 2024-08-15 → 2025-08-14
Cigna
Profee · OPHC_NEXTGEN · 2024-08-15 → 2025-08-14
Base terms — first match wins
  1. flat $0 — when NoncoverageStatus Noncovered is present
  2. 100% of Medicare lab
  3. 100% of Medicare drug
  4. 100% of Medicare DME
  5. 111% of Medicare RVU
  6. 0% of billed charges
Adjustments — all apply, in order
  1. Medicare multiple-procedure reduction — base codes 2, 3; pays 100/50% — when Modifier 55 is absent; Modifier 82 is absent
  2. Medicare multiple-endoscopy reduction
  3. Medicare multiple-radiology reduction — base codes 4
  4. Medicare bilateral-surgery adjustment
  5. mid-level provider reduction (by NUCC taxonomy)
  6. modifier 22 present → 135% of the running amount
  7. modifier 52 present → 50% of the running amount
  8. custom SQL — Same global-surgery post-op allocation as hash c5fd5754fcf4a52d (Allowed/GlobalDays*PostOpRate), but hardened: falls back to returning {Allowed} unchanged when GLOB_DAYS or POST_OP is missing/non-numeric/zero instead of dividing by zero. — when Modifier 55 is present
  9. modifier 54 present → 80% of the running amount
  10. modifier 62 present → 62.5% of the running amount
  11. modifier 73 present → 50% of the running amount
  12. modifier 78 present → 70% of the running amount
  13. modifier 80 present → 16% of the running amount
  14. modifier 81 present → 16% of the running amount
  15. modifier 82 present → 16% of the running amount
  16. modifier AS present → 14% of the running amount
  17. modifier QY present → 50% of the running amount
  18. modifier QK present → 50% of the running amount
  19. modifier QX present → 50% of the running amount
  20. cap each charge and the account total at 100% of billed charges
QVC - Cigna Profees (8.15.25 to 8.14.26)6 base · 20 adj
Cigna
Profee · QUANTUM · 2025-08-15 → 2026-08-14
Cigna
Profee · OPHC_NEXTGEN · 2025-08-15 → 2026-08-14
Base terms — first match wins
  1. flat $0 — when NoncoverageStatus Noncovered is present
  2. 100% of Medicare lab
  3. 100% of Medicare drug
  4. 100% of Medicare DME
  5. 115% of Medicare RVU
  6. 0% of billed charges
Adjustments — all apply, in order
  1. Medicare multiple-procedure reduction — base codes 2, 3; pays 100/50% — when Modifier 55 is absent; Modifier 82 is absent
  2. Medicare multiple-endoscopy reduction
  3. Medicare multiple-radiology reduction — base codes 4
  4. Medicare bilateral-surgery adjustment
  5. mid-level provider reduction (by NUCC taxonomy)
  6. modifier 22 present → 135% of the running amount
  7. modifier 52 present → 50% of the running amount
  8. custom SQL — Same global-surgery post-op allocation as hash c5fd5754fcf4a52d (Allowed/GlobalDays*PostOpRate), but hardened: falls back to returning {Allowed} unchanged when GLOB_DAYS or POST_OP is missing/non-numeric/zero instead of dividing by zero. — when Modifier 55 is present
  9. modifier 54 present → 80% of the running amount
  10. modifier 62 present → 62.5% of the running amount
  11. modifier 73 present → 50% of the running amount
  12. modifier 78 present → 70% of the running amount
  13. modifier 80 present → 16% of the running amount
  14. modifier 81 present → 16% of the running amount
  15. modifier 82 present → 16% of the running amount
  16. modifier AS present → 14% of the running amount
  17. modifier QY present → 50% of the running amount
  18. modifier QK present → 50% of the running amount
  19. modifier QX present → 50% of the running amount
  20. cap each charge and the account total at 100% of billed charges
RAK - Anthem HMO Profees (11.01.2024)4 base · 21 adj
Anthem HMO
Profee · RAK, Clinic · 2024-11-01 → 2999-12-31
Base terms — first match wins
  1. flat $0 — when NoncoverageStatus Noncovered is present
  2. 100% of Medicare drug
  3. 100% of the Carveouts fee schedule
  4. 100% of the Profee-Fees fee schedule
Adjustments — all apply, in order
  1. Medicare multiple-procedure reduction — base codes 2, 3; pays 100/50% — when Modifier 55 is absent; Modifier 82 is absent
  2. Medicare multiple-endoscopy reduction
  3. Medicare multiple-ophthalmology reduction — base codes 7; pays 100/80%
  4. Medicare multiple-radiology reduction — base codes 4
  5. Medicare bilateral-surgery adjustment
  6. mid-level provider reduction (by NUCC taxonomy)
  7. modifier 22 present → 135% of the running amount
  8. modifier 52 present → 50% of the running amount
  9. custom SQL — Same global-surgery post-op allocation as hash c5fd5754fcf4a52d (Allowed/GlobalDays*PostOpRate), but hardened: falls back to returning {Allowed} unchanged when GLOB_DAYS or POST_OP is missing/non-numeric/zero instead of dividing by zero. — when Modifier 55 is present
  10. modifier 54 present → 80% of the running amount
  11. modifier 62 present → 62.5% of the running amount
  12. modifier 73 present → 50% of the running amount
  13. modifier 78 present → 70% of the running amount
  14. modifier 80 present → 16% of the running amount
  15. modifier 81 present → 16% of the running amount
  16. modifier 82 present → 16% of the running amount
  17. modifier AS present → 14% of the running amount
  18. modifier QY present → 50% of the running amount
  19. modifier QK present → 50% of the running amount
  20. modifier QX present → 50% of the running amount
  21. cap each charge and the account total at 100% of billed charges
RAK - Anthem PPO Profees (11.01.2024)5 base · 21 adj
Anthem PPO
Profee · RAK, Clinic · 2024-11-01 → 2999-12-31
Base terms — first match wins
  1. flat $0 — when NoncoverageStatus Noncovered is present
  2. custom SQL — Zeroes the allowed amount for any charge whose ChargeType code ends in the 'NC' suffix — the customer's local naming convention for marking a code as non-covered.
  3. 100% of Medicare drug
  4. 100% of the Carveouts fee schedule
  5. 100% of the Anthem PPO Profee Fee Schedules fee schedule
Adjustments — all apply, in order
  1. Medicare multiple-procedure reduction — base codes 2, 3; pays 100/50% — when Modifier 55 is absent; Modifier 82 is absent
  2. Medicare multiple-endoscopy reduction
  3. Medicare multiple-ophthalmology reduction — base codes 7; pays 100/80%
  4. Medicare multiple-radiology reduction — base codes 4
  5. Medicare bilateral-surgery adjustment
  6. mid-level provider reduction (by NUCC taxonomy)
  7. modifier 22 present → 135% of the running amount
  8. modifier 52 present → 50% of the running amount
  9. custom SQL — Same global-surgery post-op allocation as hash c5fd5754fcf4a52d (Allowed/GlobalDays*PostOpRate), but hardened: falls back to returning {Allowed} unchanged when GLOB_DAYS or POST_OP is missing/non-numeric/zero instead of dividing by zero. — when Modifier 55 is present
  10. modifier 54 present → 80% of the running amount
  11. modifier 62 present → 62.5% of the running amount
  12. modifier 73 present → 50% of the running amount
  13. modifier 78 present → 70% of the running amount
  14. modifier 80 present → 16% of the running amount
  15. modifier 81 present → 16% of the running amount
  16. modifier 82 present → 16% of the running amount
  17. modifier AS present → 14% of the running amount
  18. modifier QY present → 50% of the running amount
  19. modifier QK present → 50% of the running amount
  20. modifier QX present → 50% of the running amount
  21. cap each charge and the account total at 100% of billed charges
RAK - Anthem PPO Profees (11.01.2024)4 base · 21 adj
Anthem PPO
Profee · RAK, Clinic · 2024-11-01 → 2999-12-31
Base terms — first match wins
  1. flat $0 — when NoncoverageStatus Noncovered is present
  2. 100% of Medicare drug
  3. 100% of the Carveouts fee schedule
  4. 100% of the Anthem PPO Profee Fee Schedules fee schedule
Adjustments — all apply, in order
  1. Medicare multiple-procedure reduction — base codes 2, 3; pays 100/50% — when Modifier 55 is absent; Modifier 82 is absent
  2. Medicare multiple-endoscopy reduction
  3. Medicare multiple-ophthalmology reduction — base codes 7; pays 100/80%
  4. Medicare multiple-radiology reduction — base codes 4
  5. Medicare bilateral-surgery adjustment
  6. mid-level provider reduction (by NUCC taxonomy)
  7. modifier 22 present → 135% of the running amount
  8. modifier 52 present → 50% of the running amount
  9. custom SQL — Same global-surgery post-op allocation as hash c5fd5754fcf4a52d (Allowed/GlobalDays*PostOpRate), but hardened: falls back to returning {Allowed} unchanged when GLOB_DAYS or POST_OP is missing/non-numeric/zero instead of dividing by zero. — when Modifier 55 is present
  10. modifier 54 present → 80% of the running amount
  11. modifier 62 present → 62.5% of the running amount
  12. modifier 73 present → 50% of the running amount
  13. modifier 78 present → 70% of the running amount
  14. modifier 80 present → 16% of the running amount
  15. modifier 81 present → 16% of the running amount
  16. modifier 82 present → 16% of the running amount
  17. modifier AS present → 14% of the running amount
  18. modifier QY present → 50% of the running amount
  19. modifier QK present → 50% of the running amount
  20. modifier QX present → 50% of the running amount
  21. cap each charge and the account total at 100% of billed charges
RAK - Humana Medicaid Profees4 base · 20 adj
Humana Medicaid
Profee · RAK · 2023-01-01 → 2999-12-31
Base terms — first match wins
  1. 45% of billed charges — when KYMedicaidBCCode True is present
  2. 102% of the Fixed-Fees-Labs fee schedule
  3. 102% of the KY-Medicaid-Profee-Fees fee schedule — when FacilityType in Clinic
  4. 102% of the KY-Medicaid-Facility-Profee-Fees fee schedule
Adjustments — all apply, in order
  1. Medicare multiple-procedure reduction — base codes 2, 3; pays 100/50% — when Modifier 55 is absent; Modifier 82 is absent
  2. Medicare multiple-endoscopy reduction
  3. Medicare multiple-radiology reduction — base codes 4
  4. mid-level provider reduction (by NUCC taxonomy)
  5. modifier 22 present → 135% of the running amount
  6. modifier 50 present → 150% of the running amount
  7. modifier 52 present → 50% of the running amount
  8. custom SQL — Same global-surgery post-op allocation as hash c5fd5754fcf4a52d (Allowed/GlobalDays*PostOpRate), but hardened: falls back to returning {Allowed} unchanged when GLOB_DAYS or POST_OP is missing/non-numeric/zero instead of dividing by zero. — when Modifier 55 is present
  9. modifier 54 present → 80% of the running amount
  10. modifier 62 present → 62.5% of the running amount
  11. modifier 73 present → 50% of the running amount
  12. modifier 78 present → 70% of the running amount
  13. modifier 80 present → 16% of the running amount
  14. modifier 81 present → 16% of the running amount
  15. modifier 82 present → 16% of the running amount
  16. modifier AS present → 14% of the running amount
  17. modifier QY present → 50% of the running amount
  18. modifier QK present → 50% of the running amount
  19. modifier QX present → 50% of the running amount
  20. cap each charge and the account total at 100% of billed charges
RAK - Humana Profees (5.1.2024)7 base · 20 adj
Humana
Profee · RAK · 2024-05-01 → 2999-12-31
Base terms — first match wins
  1. flat $0 — when NoncoverageStatus Noncovered is present
  2. 130% of Medicare lab
  3. 100% of Medicare drug
  4. 130% of Medicare DME
  5. 130% of Medicare RVU — when PlaceOfService 2 is present
  6. 130% of Medicare RVU
  7. 0% of billed charges
Adjustments — all apply, in order
  1. Medicare multiple-procedure reduction — base codes 2, 3; pays 100/50% — when Modifier 55 is absent; Modifier 82 is absent
  2. Medicare multiple-endoscopy reduction
  3. Medicare multiple-radiology reduction — base codes 4
  4. Medicare bilateral-surgery adjustment
  5. mid-level provider reduction (by NUCC taxonomy)
  6. modifier 22 present → 135% of the running amount
  7. modifier 52 present → 50% of the running amount
  8. custom SQL — Same global-surgery post-op allocation as hash c5fd5754fcf4a52d (Allowed/GlobalDays*PostOpRate), but hardened: falls back to returning {Allowed} unchanged when GLOB_DAYS or POST_OP is missing/non-numeric/zero instead of dividing by zero. — when Modifier 55 is present
  9. modifier 54 present → 80% of the running amount
  10. modifier 62 present → 62.5% of the running amount
  11. modifier 73 present → 50% of the running amount
  12. modifier 78 present → 70% of the running amount
  13. modifier 80 present → 16% of the running amount
  14. modifier 81 present → 16% of the running amount
  15. modifier 82 present → 16% of the running amount
  16. modifier AS present → 14% of the running amount
  17. modifier QY present → 50% of the running amount
  18. modifier QK present → 50% of the running amount
  19. modifier QX present → 50% of the running amount
  20. cap each charge and the account total at 100% of billed charges
RAK-Anthem Federal7 base · 20 adj
Anthem Federal
Profee · RAK · 2024-01-01 → 2999-12-31
Base terms — first match wins
  1. flat $0 — when NoncoverageStatus Noncovered is present
  2. 100% of Medicare lab
  3. 100% of Medicare drug
  4. 100% of Medicare DME
  5. 100% of Medicare RVU — when PlaceOfService 2 is present
  6. 100% of Medicare RVU
  7. 0% of billed charges
Adjustments — all apply, in order
  1. Medicare multiple-procedure reduction — base codes 2, 3; pays 100/50% — when Modifier 55 is absent; Modifier 82 is absent
  2. Medicare multiple-endoscopy reduction
  3. Medicare multiple-radiology reduction — base codes 4
  4. Medicare bilateral-surgery adjustment
  5. mid-level provider reduction (by NUCC taxonomy)
  6. modifier 22 present → 135% of the running amount
  7. modifier 52 present → 50% of the running amount
  8. modifier 54 present → 80% of the running amount
  9. custom SQL — Same global-surgery post-op allocation as hash c5fd5754fcf4a52d (Allowed/GlobalDays*PostOpRate), but hardened: falls back to returning {Allowed} unchanged when GLOB_DAYS or POST_OP is missing/non-numeric/zero instead of dividing by zero. — when Modifier 55 is present
  10. modifier 62 present → 62.5% of the running amount
  11. modifier 73 present → 50% of the running amount
  12. modifier 78 present → 70% of the running amount
  13. modifier 80 present → 16% of the running amount
  14. modifier 81 present → 16% of the running amount
  15. modifier 82 present → 16% of the running amount
  16. modifier AS present → 14% of the running amount
  17. modifier QY present → 50% of the running amount
  18. modifier QK present → 50% of the running amount
  19. modifier QX present → 50% of the running amount
  20. cap each charge and the account total at 100% of billed charges
RAK-Anthem Federal Medicare7 base · 20 adj
Anthem Federal Medicare
Profee · RAK · 2024-01-01 → 2999-12-31
Base terms — first match wins
  1. flat $0 — when NoncoverageStatus Noncovered is present
  2. 100% of Medicare lab
  3. 100% of Medicare drug
  4. 100% of Medicare DME
  5. 100% of Medicare RVU — when PlaceOfService 2 is present
  6. 100% of Medicare RVU
  7. 0% of billed charges
Adjustments — all apply, in order
  1. Medicare multiple-procedure reduction — base codes 2, 3; pays 100/50% — when Modifier 55 is absent; Modifier 82 is absent
  2. Medicare multiple-endoscopy reduction
  3. Medicare multiple-radiology reduction — base codes 4
  4. Medicare bilateral-surgery adjustment
  5. mid-level provider reduction (by NUCC taxonomy)
  6. modifier 22 present → 135% of the running amount
  7. modifier 52 present → 50% of the running amount
  8. modifier 54 present → 80% of the running amount
  9. custom SQL — Same global-surgery post-op allocation as hash c5fd5754fcf4a52d (Allowed/GlobalDays*PostOpRate), but hardened: falls back to returning {Allowed} unchanged when GLOB_DAYS or POST_OP is missing/non-numeric/zero instead of dividing by zero. — when Modifier 55 is present
  10. modifier 62 present → 62.5% of the running amount
  11. modifier 73 present → 50% of the running amount
  12. modifier 78 present → 70% of the running amount
  13. modifier 80 present → 16% of the running amount
  14. modifier 81 present → 16% of the running amount
  15. modifier 82 present → 16% of the running amount
  16. modifier AS present → 14% of the running amount
  17. modifier QY present → 50% of the running amount
  18. modifier QK present → 50% of the running amount
  19. modifier QX present → 50% of the running amount
  20. cap each charge and the account total at 100% of billed charges
RAK-Humana-Profee4 base · 20 adj
Humana
Profee · RAK, Clinic, Home · 2023-01-01 → 2024-04-30
Base terms — first match wins
  1. flat $0 — when NoncoverageStatus Noncovered is present
  2. 100% of Medicare drug
  3. 100% of the Profee-Drug fee schedule
  4. 100% of the Profee-Fees fee schedule
Adjustments — all apply, in order
  1. Medicare multiple-procedure reduction — base codes 2, 3; pays 100/50% — when Modifier 55 is absent; Modifier 82 is absent
  2. Medicare multiple-endoscopy reduction
  3. Medicare multiple-radiology reduction — base codes 4
  4. Medicare bilateral-surgery adjustment
  5. mid-level provider reduction (by NUCC taxonomy)
  6. modifier 22 present → 135% of the running amount
  7. modifier 52 present → 50% of the running amount
  8. custom SQL — Same global-surgery post-op allocation as hash c5fd5754fcf4a52d (Allowed/GlobalDays*PostOpRate), but hardened: falls back to returning {Allowed} unchanged when GLOB_DAYS or POST_OP is missing/non-numeric/zero instead of dividing by zero. — when Modifier 55 is present
  9. modifier 54 present → 80% of the running amount
  10. modifier 62 present → 62.5% of the running amount
  11. modifier 73 present → 50% of the running amount
  12. modifier 78 present → 70% of the running amount
  13. modifier 80 present → 16% of the running amount
  14. modifier 81 present → 16% of the running amount
  15. modifier 82 present → 16% of the running amount
  16. modifier AS present → 14% of the running amount
  17. modifier QY present → 50% of the running amount
  18. modifier QK present → 50% of the running amount
  19. modifier QX present → 50% of the running amount
  20. cap each charge and the account total at 100% of billed charges
RAK-United Healthcare-Profees3 base · 22 adj
United Healthcare
Profee · RAK · 2023-01-01 → 2999-12-31
Base terms — first match wins
  1. 100% of Medicare drug
  2. flat $0 — when NoncoverageStatus Noncovered is present
  3. 100% of the RAK-UHC-Profee-Fees fee schedule
Adjustments — all apply, in order
  1. Medicare multiple-procedure reduction — base codes 2, 3; pays 100/50% — when Modifier 55 is absent; Modifier 82 is absent
  2. Medicare multiple-endoscopy reduction
  3. Medicare multiple-radiology reduction — base codes 4
  4. Medicare bilateral-surgery adjustment
  5. mid-level provider reduction (by NUCC taxonomy)
  6. modifier 22 present → 135% of the running amount
  7. modifier 52 present → 50% of the running amount
  8. modifier 53 present → 25% of the running amount
  9. custom SQL — Same global-surgery post-op allocation as hash c5fd5754fcf4a52d (Allowed/GlobalDays*PostOpRate), but hardened: falls back to returning {Allowed} unchanged when GLOB_DAYS or POST_OP is missing/non-numeric/zero instead of dividing by zero. — when Modifier 55 is present
  10. modifier 54 present → 80% of the running amount
  11. modifier 62 present → 62.5% of the running amount
  12. modifier 73 present → 50% of the running amount
  13. modifier 78 present → 70% of the running amount
  14. modifier 80 present → 16% of the running amount
  15. modifier 81 present → 16% of the running amount
  16. modifier 82 present → 16% of the running amount
  17. modifier AS present → 14% of the running amount
  18. modifier QY present → 50% of the running amount
  19. modifier QK present → 50% of the running amount
  20. modifier QX present → 50% of the running amount
  21. modifier QZ present → 85% of the running amount
  22. cap each charge and the account total at 100% of billed charges
Sabates - Aetna Medicare Profees6 base · 21 adj
Aetna Medicare
Profee · SABATES_EYE · 2023-01-01 → 2023-12-31
Base terms — first match wins
  1. flat $0 — when NoncoverageStatus Noncovered is present
  2. 95% of Medicare lab
  3. 100% of Medicare drug
  4. 95% of Medicare DME
  5. 95% of Medicare RVU
  6. 0% of billed charges
Adjustments — all apply, in order
  1. Medicare multiple-procedure reduction — base codes 2, 3; pays 100/50/25% — when Modifier 55 is absent; Modifier 82 is absent
  2. Medicare multiple-ophthalmology reduction — base codes 7; pays 100/80%
  3. Medicare multiple-endoscopy reduction
  4. Medicare multiple-radiology reduction — base codes 4
  5. Medicare bilateral-surgery adjustment
  6. mid-level provider reduction (by NUCC taxonomy)
  7. modifier 22 present → 135% of the running amount
  8. modifier 52 present → 50% of the running amount
  9. custom SQL — Same global-surgery post-op allocation as hash c5fd5754fcf4a52d (Allowed/GlobalDays*PostOpRate), but hardened: falls back to returning {Allowed} unchanged when GLOB_DAYS or POST_OP is missing/non-numeric/zero instead of dividing by zero. — when Modifier 55 is present
  10. modifier 54 present → 80% of the running amount
  11. modifier 62 present → 62.5% of the running amount
  12. modifier 73 present → 50% of the running amount
  13. modifier 78 present → 70% of the running amount
  14. modifier 80 present → 16% of the running amount
  15. modifier 81 present → 16% of the running amount
  16. modifier 82 present → 16% of the running amount
  17. modifier AS present → 14% of the running amount
  18. modifier QY present → 50% of the running amount
  19. modifier QK present → 50% of the running amount
  20. modifier QX present → 50% of the running amount
  21. cap each charge and the account total at 100% of billed charges
Sabates - Aetna Medicare Profees6 base · 21 adj
Aetna Medicare
Profee · SABATES_EYE · 2024-01-01 → 2999-12-31
Base terms — first match wins
  1. flat $0 — when NoncoverageStatus Noncovered is present
  2. 95% of Medicare lab
  3. 95% of Medicare drug
  4. 95% of Medicare DME
  5. 95% of Medicare RVU
  6. 0% of billed charges
Adjustments — all apply, in order
  1. Medicare multiple-procedure reduction — base codes 2, 3; pays 100/50/25% — when Modifier 55 is absent; Modifier 82 is absent
  2. Medicare multiple-ophthalmology reduction — base codes 7; pays 100/80%
  3. Medicare multiple-endoscopy reduction
  4. Medicare multiple-radiology reduction — base codes 4
  5. Medicare bilateral-surgery adjustment
  6. mid-level provider reduction (by NUCC taxonomy)
  7. modifier 22 present → 135% of the running amount
  8. modifier 52 present → 50% of the running amount
  9. custom SQL — Same global-surgery post-op allocation as hash c5fd5754fcf4a52d (Allowed/GlobalDays*PostOpRate), but hardened: falls back to returning {Allowed} unchanged when GLOB_DAYS or POST_OP is missing/non-numeric/zero instead of dividing by zero. — when Modifier 55 is present
  10. modifier 54 present → 80% of the running amount
  11. modifier 62 present → 62.5% of the running amount
  12. modifier 73 present → 50% of the running amount
  13. modifier 78 present → 70% of the running amount
  14. modifier 80 present → 16% of the running amount
  15. modifier 81 present → 16% of the running amount
  16. modifier 82 present → 16% of the running amount
  17. modifier AS present → 14% of the running amount
  18. modifier QY present → 50% of the running amount
  19. modifier QK present → 50% of the running amount
  20. modifier QX present → 50% of the running amount
  21. cap each charge and the account total at 100% of billed charges
Sabates-Tricare Profees (2024)4 base · 20 adj
Tricare
Profee · SABATES_EYE · 2023-10-15 → 2024-12-31
Base terms — first match wins
  1. flat $0 — when NoncoverageStatus Noncovered is present
  2. 88% of the Tricare-Drug fee schedule
  3. 88% of the Tricare-CMAC-Technical fee schedule
  4. 88% of the Tricare-CMAC fee schedule
Adjustments — all apply, in order
  1. Medicare multiple-procedure reduction — base codes 2, 3; pays 100/50% — when Modifier 55 is absent; Modifier 82 is absent
  2. Medicare multiple-endoscopy reduction
  3. Medicare multiple-radiology reduction — base codes 4
  4. Medicare bilateral-surgery adjustment
  5. mid-level provider reduction (by NUCC taxonomy)
  6. modifier 22 present → 135% of the running amount
  7. modifier 52 present → 50% of the running amount
  8. custom SQL — Same global-surgery post-op allocation as hash c5fd5754fcf4a52d (Allowed/GlobalDays*PostOpRate), but hardened: falls back to returning {Allowed} unchanged when GLOB_DAYS or POST_OP is missing/non-numeric/zero instead of dividing by zero. — when Modifier 55 is present
  9. modifier 54 present → 80% of the running amount
  10. modifier 62 present → 62.5% of the running amount
  11. modifier 73 present → 50% of the running amount
  12. modifier 78 present → 70% of the running amount
  13. modifier 80 present → 16% of the running amount
  14. modifier 81 present → 16% of the running amount
  15. modifier 82 present → 16% of the running amount
  16. modifier AS present → 14% of the running amount
  17. modifier QY present → 50% of the running amount
  18. modifier QK present → 50% of the running amount
  19. modifier QX present → 50% of the running amount
  20. cap each charge and the account total at 70% of billed charges
Sabates-Tricare Profees (2025)4 base · 20 adj
Tricare
Profee · SABATES_EYE · 2025-01-01 → 2999-12-31
Base terms — first match wins
  1. flat $0 — when NoncoverageStatus Noncovered is present
  2. 100% of the Tricare-Drug fee schedule
  3. 100% of the Tricare-CMAC-Technical fee schedule
  4. 100% of the Tricare-CMAC fee schedule
Adjustments — all apply, in order
  1. Medicare multiple-procedure reduction — base codes 2, 3; pays 100/50% — when Modifier 55 is absent; Modifier 82 is absent
  2. Medicare multiple-endoscopy reduction
  3. Medicare multiple-radiology reduction — base codes 4
  4. Medicare bilateral-surgery adjustment
  5. mid-level provider reduction (by NUCC taxonomy)
  6. modifier 22 present → 135% of the running amount
  7. modifier 52 present → 50% of the running amount
  8. custom SQL — Same global-surgery post-op allocation as hash c5fd5754fcf4a52d (Allowed/GlobalDays*PostOpRate), but hardened: falls back to returning {Allowed} unchanged when GLOB_DAYS or POST_OP is missing/non-numeric/zero instead of dividing by zero. — when Modifier 55 is present
  9. modifier 54 present → 80% of the running amount
  10. modifier 62 present → 62.5% of the running amount
  11. modifier 73 present → 50% of the running amount
  12. modifier 78 present → 70% of the running amount
  13. modifier 80 present → 16% of the running amount
  14. modifier 81 present → 16% of the running amount
  15. modifier 82 present → 16% of the running amount
  16. modifier AS present → 14% of the running amount
  17. modifier QY present → 50% of the running amount
  18. modifier QK present → 50% of the running amount
  19. modifier QX present → 50% of the running amount
  20. cap each charge and the account total at 100% of billed charges
Self-Pay1 base · 0 adj
Self Pay
Facility, Profee · all facilities · 2023-01-01 → 2999-12-31
Base terms — first match wins
  1. 100% of billed charges
Sentara-VA-ASC-Commercial-Groupers6 base · 22 adj
Sentara Commercial, Sentara Optima
Facility · CVP_MIDATLANTIC · 2022-01-01 → 2999-12-31
Base terms — first match wins
  1. flat $0 — when NoncoverageStatus Noncovered is present
  2. 10% of billed charges — when Modifier 73 is present
  3. 20% of billed charges — when Modifier 74 is present
  4. 100% of billed charges — when ProcedureCode V2785 is present
  5. 100% of the Facility-Fees fee schedule
  6. flat $744
Adjustments — all apply, in order
  1. Medicare multiple-procedure reduction — base codes 2; pays 100/50/50/50/50/0%
  2. Medicare multiple-endoscopy reduction
  3. Medicare multiple-radiology reduction — base codes 4
  4. Medicare bilateral-surgery adjustment
  5. mid-level provider reduction (by NUCC taxonomy)
  6. modifier 22 present → 135% of the running amount
  7. modifier 50 present → 150% of the running amount
  8. modifier 52 present → 50% of the running amount
  9. custom SQL — Same global-surgery post-op allocation as hash c5fd5754fcf4a52d (Allowed/GlobalDays*PostOpRate), but hardened: falls back to returning {Allowed} unchanged when GLOB_DAYS or POST_OP is missing/non-numeric/zero instead of dividing by zero. — when Modifier 55 is present
  10. modifier 54 present → 80% of the running amount
  11. modifier 62 present → 62.5% of the running amount
  12. modifier 78 present → 70% of the running amount
  13. modifier 80 present → 16% of the running amount
  14. modifier 81 present → 16% of the running amount
  15. modifier 82 present → 16% of the running amount
  16. modifier AS present → 14% of the running amount
  17. modifier QY present → 50% of the running amount
  18. modifier QK present → 50% of the running amount
  19. modifier QX present → 50% of the running amount
  20. modifier 73 present → 10% of the running amount
  21. modifier 74 present → 20% of the running amount
  22. cap each charge and the account total at 100% of billed charges
St Petersburg - UHC Medicare Facility Fees5 base · 21 adj
United Healthcare Medicare
Facility · StPetersburgASC · 2023-01-01 → 2999-12-31
Base terms — first match wins
  1. flat $0 — when NoncoverageStatus Noncovered is present
  2. 25% of billed charges — when ProcedureCode C9399 is present
  3. 100% of the Carveouts fee schedule
  4. 90% of Medicare ASC
  5. 0% of billed charges
Adjustments — all apply, in order
  1. Medicare multiple-procedure reduction — base codes 2; pays 100/50/25/0%
  2. Medicare multiple-endoscopy reduction
  3. Medicare multiple-radiology reduction — base codes 4
  4. Medicare bilateral-surgery adjustment
  5. mid-level provider reduction (by NUCC taxonomy)
  6. modifier 22 present → 135% of the running amount
  7. modifier 52 present → 50% of the running amount
  8. modifier 53 present → 25% of the running amount
  9. custom SQL — Same global-surgery post-op allocation as hash c5fd5754fcf4a52d (Allowed/GlobalDays*PostOpRate), but hardened: falls back to returning {Allowed} unchanged when GLOB_DAYS or POST_OP is missing/non-numeric/zero instead of dividing by zero. — when Modifier 55 is present
  10. modifier 54 present → 80% of the running amount
  11. modifier 62 present → 62.5% of the running amount
  12. modifier 73 present → 50% of the running amount
  13. modifier 78 present → 70% of the running amount
  14. modifier 80 present → 16% of the running amount
  15. modifier 81 present → 16% of the running amount
  16. modifier 82 present → 16% of the running amount
  17. modifier AS present → 14% of the running amount
  18. modifier QY present → 50% of the running amount
  19. modifier QK present → 50% of the running amount
  20. modifier QX present → 50% of the running amount
  21. cap each charge and the account total at 100% of billed charges
StilesEyecare-Aetna-Profee3 base · 21 adj
Aetna
Profee · STILES · 2023-01-01 → 2999-12-31
Base terms — first match wins
  1. flat $0 — when NoncoverageStatus Noncovered is present
  2. 100% of Medicare drug
  3. 100% of the Profee-Fees fee schedule
Adjustments — all apply, in order
  1. Medicare multiple-procedure reduction — base codes 2, 3; pays 100/50/25% — when Modifier 55 is absent; Modifier 82 is absent
  2. Medicare multiple-ophthalmology reduction — base codes 7; pays 100/80%
  3. Medicare multiple-endoscopy reduction
  4. Medicare multiple-radiology reduction — base codes 4
  5. Medicare bilateral-surgery adjustment
  6. mid-level provider reduction (by NUCC taxonomy)
  7. modifier 22 present → 135% of the running amount
  8. modifier 52 present → 50% of the running amount
  9. custom SQL — Same global-surgery post-op allocation as hash c5fd5754fcf4a52d (Allowed/GlobalDays*PostOpRate), but hardened: falls back to returning {Allowed} unchanged when GLOB_DAYS or POST_OP is missing/non-numeric/zero instead of dividing by zero. — when Modifier 55 is present
  10. modifier 54 present → 80% of the running amount
  11. modifier 62 present → 62.5% of the running amount
  12. modifier 73 present → 50% of the running amount
  13. modifier 78 present → 70% of the running amount
  14. modifier 80 present → 16% of the running amount
  15. modifier 81 present → 16% of the running amount
  16. modifier 82 present → 16% of the running amount
  17. modifier AS present → 14% of the running amount
  18. modifier QY present → 50% of the running amount
  19. modifier QK present → 50% of the running amount
  20. modifier QX present → 50% of the running amount
  21. cap each charge and the account total at 100% of billed charges
StilesEyecare-HumanaMedicare-Profee3 base · 20 adj
Humana Medicare
Profee · STILES · 2023-01-01 → 2999-12-31
Base terms — first match wins
  1. flat $0 — when NoncoverageStatus Noncovered is present
  2. 100% of Medicare drug
  3. 100% of the Profee-Fees fee schedule
Adjustments — all apply, in order
  1. Medicare multiple-procedure reduction — base codes 2, 3; pays 100/50% — when Modifier 55 is absent; Modifier 82 is absent
  2. Medicare multiple-endoscopy reduction
  3. Medicare multiple-radiology reduction — base codes 4
  4. Medicare bilateral-surgery adjustment
  5. mid-level provider reduction (by NUCC taxonomy)
  6. modifier 22 present → 135% of the running amount
  7. modifier 52 present → 50% of the running amount
  8. custom SQL — Same global-surgery post-op allocation as hash c5fd5754fcf4a52d (Allowed/GlobalDays*PostOpRate), but hardened: falls back to returning {Allowed} unchanged when GLOB_DAYS or POST_OP is missing/non-numeric/zero instead of dividing by zero. — when Modifier 55 is present
  9. modifier 54 present → 80% of the running amount
  10. modifier 62 present → 62.5% of the running amount
  11. modifier 73 present → 50% of the running amount
  12. modifier 78 present → 70% of the running amount
  13. modifier 80 present → 16% of the running amount
  14. modifier 81 present → 16% of the running amount
  15. modifier 82 present → 16% of the running amount
  16. modifier AS present → 14% of the running amount
  17. modifier QY present → 50% of the running amount
  18. modifier QK present → 50% of the running amount
  19. modifier QX present → 50% of the running amount
  20. cap each charge and the account total at 100% of billed charges
StilesEyecare-UHC-Medicare-Profee3 base · 21 adj
United Healthcare Medicare
Profee · STILES · 2023-01-01 → 2999-12-31
Base terms — first match wins
  1. flat $0 — when NoncoverageStatus Noncovered is present
  2. 100% of Medicare drug
  3. 100% of the Profee-Fees fee schedule
Adjustments — all apply, in order
  1. Medicare multiple-procedure reduction — base codes 2, 3; pays 100/50% — when Modifier 55 is absent; Modifier 82 is absent
  2. Medicare multiple-endoscopy reduction
  3. Medicare multiple-radiology reduction — base codes 4
  4. Medicare bilateral-surgery adjustment
  5. mid-level provider reduction (by NUCC taxonomy)
  6. modifier 22 present → 135% of the running amount
  7. modifier 52 present → 50% of the running amount
  8. modifier 53 present → 25% of the running amount
  9. custom SQL — Same global-surgery post-op allocation as hash c5fd5754fcf4a52d (Allowed/GlobalDays*PostOpRate), but hardened: falls back to returning {Allowed} unchanged when GLOB_DAYS or POST_OP is missing/non-numeric/zero instead of dividing by zero. — when Modifier 55 is present
  10. modifier 54 present → 80% of the running amount
  11. modifier 62 present → 62.5% of the running amount
  12. modifier 73 present → 50% of the running amount
  13. modifier 78 present → 70% of the running amount
  14. modifier 80 present → 16% of the running amount
  15. modifier 81 present → 16% of the running amount
  16. modifier 82 present → 16% of the running amount
  17. modifier AS present → 14% of the running amount
  18. modifier QY present → 50% of the running amount
  19. modifier QK present → 50% of the running amount
  20. modifier QX present → 50% of the running amount
  21. cap each charge and the account total at 100% of billed charges
StilesEyecare-UHC-Profee3 base · 22 adj
United Healthcare
Profee · STILES · 2023-01-01 → 2999-12-31
Base terms — first match wins
  1. flat $0 — when NoncoverageStatus Noncovered is present
  2. 100% of Medicare drug
  3. 100% of the Profee-Fees fee schedule
Adjustments — all apply, in order
  1. Medicare multiple-procedure reduction — base codes 2, 3; pays 100/50% — when Modifier 55 is absent; Modifier 82 is absent
  2. Medicare multiple-endoscopy reduction
  3. Medicare multiple-radiology reduction — base codes 4
  4. Medicare bilateral-surgery adjustment
  5. mid-level provider reduction (by NUCC taxonomy)
  6. modifier 22 present → 135% of the running amount
  7. modifier 52 present → 50% of the running amount
  8. modifier 53 present → 25% of the running amount
  9. custom SQL — Same global-surgery post-op allocation as hash c5fd5754fcf4a52d (Allowed/GlobalDays*PostOpRate), but hardened: falls back to returning {Allowed} unchanged when GLOB_DAYS or POST_OP is missing/non-numeric/zero instead of dividing by zero. — when Modifier 55 is present
  10. modifier 54 present → 80% of the running amount
  11. modifier 62 present → 62.5% of the running amount
  12. modifier 73 present → 50% of the running amount
  13. modifier 78 present → 70% of the running amount
  14. modifier 80 present → 16% of the running amount
  15. modifier 81 present → 16% of the running amount
  16. modifier 82 present → 16% of the running amount
  17. modifier AS present → 14% of the running amount
  18. modifier QY present → 50% of the running amount
  19. modifier QK present → 50% of the running amount
  20. modifier QX present → 50% of the running amount
  21. modifier QZ present → 85% of the running amount
  22. cap each charge and the account total at 100% of billed charges
Tricare-Profee4 base · 20 adj
Tricare
Profee · SABATES_EYE · 2023-01-01 → 2023-10-14
Base terms — first match wins
  1. flat $0 — when NoncoverageStatus Noncovered is present
  2. 100% of the Tricare-Drug fee schedule
  3. 100% of the Tricare-CMAC-Technical fee schedule
  4. 100% of the Tricare-CMAC fee schedule
Adjustments — all apply, in order
  1. Medicare multiple-procedure reduction — base codes 2, 3; pays 100/50% — when Modifier 55 is absent; Modifier 82 is absent
  2. Medicare multiple-endoscopy reduction
  3. Medicare multiple-radiology reduction — base codes 4
  4. Medicare bilateral-surgery adjustment
  5. mid-level provider reduction (by NUCC taxonomy)
  6. modifier 22 present → 135% of the running amount
  7. modifier 52 present → 50% of the running amount
  8. custom SQL — Same global-surgery post-op allocation as hash c5fd5754fcf4a52d (Allowed/GlobalDays*PostOpRate), but hardened: falls back to returning {Allowed} unchanged when GLOB_DAYS or POST_OP is missing/non-numeric/zero instead of dividing by zero. — when Modifier 55 is present
  9. modifier 54 present → 80% of the running amount
  10. modifier 62 present → 62.5% of the running amount
  11. modifier 73 present → 50% of the running amount
  12. modifier 78 present → 70% of the running amount
  13. modifier 80 present → 16% of the running amount
  14. modifier 81 present → 16% of the running amount
  15. modifier 82 present → 16% of the running amount
  16. modifier AS present → 14% of the running amount
  17. modifier QY present → 50% of the running amount
  18. modifier QK present → 50% of the running amount
  19. modifier QX present → 50% of the running amount
  20. cap each charge and the account total at 100% of billed charges
UHC-Medicare3 base · 21 adj
United Healthcare Medicare
Profee · SABATES_EYE · 2022-08-30 → 2999-12-31
United Healthcare Medicare
Profee · RAK · 2025-02-01 → 2999-12-31
Base terms — first match wins
  1. 100% of Medicare drug
  2. flat $0 — when NoncoverageStatus Noncovered is present
  3. 100% of the Profee-Fees fee schedule
Adjustments — all apply, in order
  1. Medicare multiple-procedure reduction — base codes 2, 3; pays 100/50% — when Modifier 55 is absent; Modifier 82 is absent
  2. Medicare multiple-endoscopy reduction
  3. Medicare multiple-radiology reduction — base codes 4
  4. Medicare bilateral-surgery adjustment
  5. mid-level provider reduction (by NUCC taxonomy)
  6. modifier 22 present → 135% of the running amount
  7. modifier 52 present → 50% of the running amount
  8. modifier 53 present → 25% of the running amount
  9. custom SQL — Same global-surgery post-op allocation as hash c5fd5754fcf4a52d (Allowed/GlobalDays*PostOpRate), but hardened: falls back to returning {Allowed} unchanged when GLOB_DAYS or POST_OP is missing/non-numeric/zero instead of dividing by zero. — when Modifier 55 is present
  10. modifier 54 present → 80% of the running amount
  11. modifier 62 present → 62.5% of the running amount
  12. modifier 73 present → 50% of the running amount
  13. modifier 78 present → 70% of the running amount
  14. modifier 80 present → 16% of the running amount
  15. modifier 81 present → 16% of the running amount
  16. modifier 82 present → 16% of the running amount
  17. modifier AS present → 14% of the running amount
  18. modifier QY present → 50% of the running amount
  19. modifier QK present → 50% of the running amount
  20. modifier QX present → 50% of the running amount
  21. cap each charge and the account total at 100% of billed charges
UHC-Medicare-VA-ASC7 base · 21 adj
United Healthcare Medicare
Facility · CVP_MIDATLANTIC, RIV · 2023-01-01 → 2999-12-31
Base terms — first match wins
  1. flat $0 — when NoncoverageStatus Noncovered is present
  2. case rate from UHC-Grouper-Case-Rate (All-level codes)
  3. 100% of billed charges — when ProcedureCode C1749 is present ⚠︎ named “25% of Charges Codes C1749, C1830, C1840, C9399” but configured at 100%
  4. 100% of billed charges — when ProcedureCode C1830 is present ⚠︎ named “25% of Charges Codes C1749, C1830, C1840, C9399” but configured at 100%
  5. 100% of billed charges — when ProcedureCode C1840 is present ⚠︎ named “25% of Charges Codes C1749, C1830, C1840, C9399” but configured at 100%
  6. 100% of billed charges — when ProcedureCode C9399 is present ⚠︎ named “25% of Charges Codes C1749, C1830, C1840, C9399” but configured at 100%
  7. 85% of Medicare ASC
Adjustments — all apply, in order
  1. Medicare multiple-procedure reduction — base codes 2, 3; pays 100/50% — when Modifier 55 is absent
  2. Medicare multiple-endoscopy reduction
  3. Medicare multiple-radiology reduction — base codes 4
  4. Medicare bilateral-surgery adjustment
  5. mid-level provider reduction (by NUCC taxonomy)
  6. modifier 22 present → 135% of the running amount
  7. modifier 52 present → 50% of the running amount
  8. modifier 53 present → 25% of the running amount
  9. custom SQL — Same global-surgery post-op allocation as hash c5fd5754fcf4a52d (Allowed/GlobalDays*PostOpRate), but hardened: falls back to returning {Allowed} unchanged when GLOB_DAYS or POST_OP is missing/non-numeric/zero instead of dividing by zero. — when Modifier 55 is present
  10. modifier 54 present → 80% of the running amount
  11. modifier 62 present → 62.5% of the running amount
  12. modifier 73 present → 50% of the running amount
  13. modifier 78 present → 70% of the running amount
  14. modifier 80 present → 16% of the running amount
  15. modifier 81 present → 16% of the running amount
  16. modifier 82 present → 16% of the running amount
  17. modifier AS present → 14% of the running amount
  18. modifier QY present → 50% of the running amount
  19. modifier QK present → 50% of the running amount
  20. modifier QX present → 50% of the running amount
  21. cap each charge and the account total at 100% of billed charges
UHC-VA-Commercial-Groupers3 base · 21 adj
United Healthcare
Facility · CVP_MIDATLANTIC · 2022-01-01 → 2999-12-31
Base terms — first match wins
  1. flat $0 — when NoncoverageStatus Noncovered is present
  2. 100% of the Carveouts fee schedule
  3. case rate from UHC-Grouper-Case-Rate (All-level codes)
Adjustments — all apply, in order
  1. Medicare multiple-procedure reduction — base codes 2, 3; pays 100/50% — when Modifier 55 is absent
  2. Medicare multiple-endoscopy reduction
  3. Medicare multiple-radiology reduction — base codes 4
  4. Medicare bilateral-surgery adjustment
  5. mid-level provider reduction (by NUCC taxonomy)
  6. modifier 22 present → 135% of the running amount
  7. modifier 52 present → 50% of the running amount
  8. modifier 53 present → 25% of the running amount
  9. custom SQL — Same global-surgery post-op allocation as hash c5fd5754fcf4a52d (Allowed/GlobalDays*PostOpRate), but hardened: falls back to returning {Allowed} unchanged when GLOB_DAYS or POST_OP is missing/non-numeric/zero instead of dividing by zero. — when Modifier 55 is present
  10. modifier 54 present → 80% of the running amount
  11. modifier 62 present → 62.5% of the running amount
  12. modifier 73 present → 50% of the running amount
  13. modifier 78 present → 70% of the running amount
  14. modifier 80 present → 16% of the running amount
  15. modifier 81 present → 16% of the running amount
  16. modifier 82 present → 16% of the running amount
  17. modifier AS present → 14% of the running amount
  18. modifier QY present → 50% of the running amount
  19. modifier QK present → 50% of the running amount
  20. modifier QX present → 50% of the running amount
  21. cap each charge and the account total at 100% of billed charges
United-Healthcare3 base · 22 adj
United Healthcare
Profee · SABATES_EYE, Clinic · 2022-08-30 → 2999-12-31
United Healthcare
Profee · SABATES_EYE, ASC, Hospital · 2022-10-10 → 2999-12-31
Base terms — first match wins
  1. 100% of Medicare drug
  2. flat $0 — when NoncoverageStatus Noncovered is present
  3. 100% of the Profee-Fees fee schedule
Adjustments — all apply, in order
  1. Medicare multiple-procedure reduction — base codes 2, 3; pays 100/50% — when Modifier 55 is absent; Modifier 82 is absent
  2. Medicare multiple-endoscopy reduction
  3. Medicare multiple-radiology reduction — base codes 4
  4. Medicare bilateral-surgery adjustment
  5. mid-level provider reduction (by NUCC taxonomy)
  6. modifier 22 present → 135% of the running amount
  7. modifier 52 present → 50% of the running amount
  8. modifier 53 present → 25% of the running amount
  9. custom SQL — Same global-surgery post-op allocation as hash c5fd5754fcf4a52d (Allowed/GlobalDays*PostOpRate), but hardened: falls back to returning {Allowed} unchanged when GLOB_DAYS or POST_OP is missing/non-numeric/zero instead of dividing by zero. — when Modifier 55 is present
  10. modifier 54 present → 80% of the running amount
  11. modifier 62 present → 62.5% of the running amount
  12. modifier 73 present → 50% of the running amount
  13. modifier 78 present → 70% of the running amount
  14. modifier 80 present → 16% of the running amount
  15. modifier 81 present → 16% of the running amount
  16. modifier 82 present → 16% of the running amount
  17. modifier AS present → 14% of the running amount
  18. modifier QY present → 50% of the running amount
  19. modifier QK present → 50% of the running amount
  20. modifier QX present → 50% of the running amount
  21. modifier QZ present → 85% of the running amount
  22. cap each charge and the account total at 100% of billed charges
VA Medicaid Profees2 base · 20 adj
Anthem Medicaid
Profee · CVP_MIDATLANTIC, RIV · 2024-01-01 → 2999-12-31
Aetna Medicaid
Profee · CVP_MIDATLANTIC · 2024-01-01 → 2999-12-31
Molina Medicaid
Profee · CVP_MIDATLANTIC · 2024-01-01 → 2999-12-31
VA Premier Medicaid
Profee · CVP_MIDATLANTIC · 2024-01-01 → 2999-12-31
United Healthcare Medicaid
Profee · CVP_MIDATLANTIC · 2024-01-01 → 2999-12-31
Sentara Medicaid
Profee · CVP_MIDATLANTIC · 2024-01-01 → 2999-12-31
Base terms — first match wins
  1. flat $0 — when NoncoverageStatus Noncovered is present
  2. custom SQL — A Virginia state Medicaid professional-fee schedule lookup, banded by patient age and outpatient/medical service type, with separate professional-component (mod 26), technical-component (mod TC), and global (no modifier) rate columns, each with its own effective-date window.
Adjustments — all apply, in order
  1. Medicare multiple-procedure reduction — base codes 2, 3; pays 100/50% — when Modifier 55 is absent; Modifier 82 is absent
  2. Medicare multiple-endoscopy reduction
  3. Medicare multiple-radiology reduction — base codes 4
  4. Medicare bilateral-surgery adjustment
  5. mid-level provider reduction (by NUCC taxonomy)
  6. modifier 22 present → 135% of the running amount
  7. modifier 52 present → 50% of the running amount
  8. custom SQL — Same global-surgery post-op allocation as hash c5fd5754fcf4a52d (Allowed/GlobalDays*PostOpRate), but hardened: falls back to returning {Allowed} unchanged when GLOB_DAYS or POST_OP is missing/non-numeric/zero instead of dividing by zero. — when Modifier 55 is present
  9. modifier 54 present → 80% of the running amount
  10. modifier 62 present → 62.5% of the running amount
  11. modifier 73 present → 50% of the running amount
  12. modifier 78 present → 70% of the running amount
  13. modifier 80 present → 16% of the running amount
  14. modifier 81 present → 16% of the running amount
  15. modifier 82 present → 16% of the running amount
  16. modifier AS present → 14% of the running amount
  17. modifier QY present → 50% of the running amount
  18. modifier QK present → 50% of the running amount
  19. modifier QX present → 50% of the running amount
  20. cap each charge and the account total at 100% of billed charges
William Holcomb - Humana Commercial Profees6 base · 20 adj
Humana
Profee · HOLCOMB · 2023-01-01 → 2999-12-31
Base terms — first match wins
  1. flat $0 — when NoncoverageStatus Noncovered is present
  2. 85% of Medicare lab
  3. 100% of Medicare drug
  4. 85% of Medicare DME
  5. 85% of Medicare RVU
  6. 0% of billed charges
Adjustments — all apply, in order
  1. Medicare multiple-procedure reduction — base codes 2, 3; pays 100/50% — when Modifier 55 is absent; Modifier 82 is absent
  2. Medicare multiple-endoscopy reduction
  3. Medicare multiple-radiology reduction — base codes 4
  4. Medicare bilateral-surgery adjustment
  5. mid-level provider reduction (by NUCC taxonomy)
  6. modifier 22 present → 135% of the running amount
  7. modifier 52 present → 50% of the running amount
  8. custom SQL — Same global-surgery post-op allocation as hash c5fd5754fcf4a52d (Allowed/GlobalDays*PostOpRate), but hardened: falls back to returning {Allowed} unchanged when GLOB_DAYS or POST_OP is missing/non-numeric/zero instead of dividing by zero. — when Modifier 55 is present
  9. modifier 54 present → 80% of the running amount
  10. modifier 62 present → 62.5% of the running amount
  11. modifier 73 present → 50% of the running amount
  12. modifier 78 present → 70% of the running amount
  13. modifier 80 present → 16% of the running amount
  14. modifier 81 present → 16% of the running amount
  15. modifier 82 present → 16% of the running amount
  16. modifier AS present → 14% of the running amount
  17. modifier QY present → 50% of the running amount
  18. modifier QK present → 50% of the running amount
  19. modifier QX present → 50% of the running amount
  20. cap each charge and the account total at 100% of billed charges

Cannot fire (8)

These have no contract map, or one whose insurance / bill-type / facility selection is empty, so nothing can ever resolve to them.

100% Profee Fees Schedule · no contract map3 base · 20 adj
no contract map — cannot be resolved
Base terms — first match wins
  1. flat $0 — when NoncoverageStatus Noncovered is present
  2. 100% of Medicare drug
  3. 100% of the Profee-Fees fee schedule
Adjustments — all apply, in order
  1. Medicare multiple-procedure reduction — base codes 2, 3; pays 100/50% — when Modifier 55 is absent; Modifier 82 is absent
  2. Medicare multiple-endoscopy reduction
  3. Medicare multiple-radiology reduction — base codes 4
  4. Medicare bilateral-surgery adjustment
  5. mid-level provider reduction (by NUCC taxonomy)
  6. modifier 22 present → 135% of the running amount
  7. modifier 52 present → 50% of the running amount
  8. custom SQL — Same global-surgery post-op allocation as hash c5fd5754fcf4a52d (Allowed/GlobalDays*PostOpRate), but hardened: falls back to returning {Allowed} unchanged when GLOB_DAYS or POST_OP is missing/non-numeric/zero instead of dividing by zero. — when Modifier 55 is present
  9. modifier 54 present → 80% of the running amount
  10. modifier 62 present → 62.5% of the running amount
  11. modifier 73 present → 50% of the running amount
  12. modifier 78 present → 70% of the running amount
  13. modifier 80 present → 16% of the running amount
  14. modifier 81 present → 16% of the running amount
  15. modifier 82 present → 16% of the running amount
  16. modifier AS present → 14% of the running amount
  17. modifier QY present → 50% of the running amount
  18. modifier QK present → 50% of the running amount
  19. modifier QX present → 50% of the running amount
  20. cap each charge and the account total at 100% of billed charges
160% Medicare · no contract map7 base · 20 adj
no contract map — cannot be resolved
Base terms — first match wins
  1. flat $0 — when NoncoverageStatus Noncovered is present
  2. 160% of Medicare lab
  3. 100% of Medicare drug
  4. 160% of Medicare DME
  5. 160% of Medicare RVU — when PlaceOfService 2 is present
  6. 160% of Medicare RVU
  7. 0% of billed charges
Adjustments — all apply, in order
  1. Medicare multiple-procedure reduction — base codes 2, 3; pays 100/50% — when Modifier 55 is absent; Modifier 82 is absent
  2. Medicare multiple-endoscopy reduction
  3. Medicare multiple-radiology reduction — base codes 4
  4. Medicare bilateral-surgery adjustment
  5. mid-level provider reduction (by NUCC taxonomy)
  6. modifier 22 present → 135% of the running amount
  7. modifier 52 present → 50% of the running amount
  8. custom SQL — Same global-surgery post-op allocation as hash c5fd5754fcf4a52d (Allowed/GlobalDays*PostOpRate), but hardened: falls back to returning {Allowed} unchanged when GLOB_DAYS or POST_OP is missing/non-numeric/zero instead of dividing by zero. — when Modifier 55 is present
  9. modifier 54 present → 80% of the running amount
  10. modifier 62 present → 62.5% of the running amount
  11. modifier 73 present → 50% of the running amount
  12. modifier 78 present → 70% of the running amount
  13. modifier 80 present → 16% of the running amount
  14. modifier 81 present → 16% of the running amount
  15. modifier 82 present → 16% of the running amount
  16. modifier AS present → 14% of the running amount
  17. modifier QY present → 50% of the running amount
  18. modifier QK present → 50% of the running amount
  19. modifier QX present → 50% of the running amount
  20. cap each charge and the account total at 100% of billed charges
160%-Medicare-ASC · no contract map3 base · 21 adj
no contract map — cannot be resolved
Base terms — first match wins
  1. flat $0 — when NoncoverageStatus Noncovered is present
  2. 160% of Medicare ASC
  3. flat $0
Adjustments — all apply, in order
  1. multiple-surgery reduction (contract rules) — pays 100/50%
  2. Medicare multiple-procedure reduction — base codes 2; pays 100/50%
  3. Medicare multiple-endoscopy reduction
  4. Medicare multiple-radiology reduction — base codes 4
  5. Medicare bilateral-surgery adjustment
  6. mid-level provider reduction (by NUCC taxonomy)
  7. modifier 22 present → 135% of the running amount
  8. modifier 52 present → 50% of the running amount
  9. custom SQL — Same global-surgery post-op allocation as hash c5fd5754fcf4a52d (Allowed/GlobalDays*PostOpRate), but hardened: falls back to returning {Allowed} unchanged when GLOB_DAYS or POST_OP is missing/non-numeric/zero instead of dividing by zero. — when Modifier 55 is present
  10. modifier 54 present → 80% of the running amount
  11. modifier 62 present → 62.5% of the running amount
  12. modifier 73 present → 50% of the running amount
  13. modifier 78 present → 70% of the running amount
  14. modifier 80 present → 16% of the running amount
  15. modifier 81 present → 16% of the running amount
  16. modifier 82 present → 16% of the running amount
  17. modifier AS present → 14% of the running amount
  18. modifier QY present → 50% of the running amount
  19. modifier QK present → 50% of the running amount
  20. modifier QX present → 50% of the running amount
  21. cap each charge and the account total at 100% of billed charges
163% Medicare · no contract map7 base · 20 adj
no contract map — cannot be resolved
Base terms — first match wins
  1. flat $0 — when NoncoverageStatus Noncovered is present
  2. 163% of Medicare lab
  3. 100% of Medicare drug
  4. 163% of Medicare DME
  5. 163% of Medicare RVU — when PlaceOfService 2 is present
  6. 163% of Medicare RVU
  7. 0% of billed charges
Adjustments — all apply, in order
  1. Medicare multiple-procedure reduction — base codes 2, 3; pays 100/50% — when Modifier 55 is absent; Modifier 82 is absent
  2. Medicare multiple-endoscopy reduction
  3. Medicare multiple-radiology reduction — base codes 4
  4. Medicare bilateral-surgery adjustment
  5. mid-level provider reduction (by NUCC taxonomy)
  6. modifier 22 present → 135% of the running amount
  7. modifier 52 present → 50% of the running amount
  8. custom SQL — Same global-surgery post-op allocation as hash c5fd5754fcf4a52d (Allowed/GlobalDays*PostOpRate), but hardened: falls back to returning {Allowed} unchanged when GLOB_DAYS or POST_OP is missing/non-numeric/zero instead of dividing by zero. — when Modifier 55 is present
  9. modifier 54 present → 80% of the running amount
  10. modifier 62 present → 62.5% of the running amount
  11. modifier 73 present → 50% of the running amount
  12. modifier 78 present → 70% of the running amount
  13. modifier 80 present → 16% of the running amount
  14. modifier 81 present → 16% of the running amount
  15. modifier 82 present → 16% of the running amount
  16. modifier AS present → 14% of the running amount
  17. modifier QY present → 50% of the running amount
  18. modifier QK present → 50% of the running amount
  19. modifier QX present → 50% of the running amount
  20. cap each charge and the account total at 100% of billed charges
Cigna-Profee · no contract map6 base · 20 adj
no contract map — cannot be resolved
Base terms — first match wins
  1. flat $0 — when NoncoverageStatus Noncovered is present
  2. 115% of Medicare lab
  3. 100% of Medicare drug
  4. 115% of Medicare DME
  5. 115% of Medicare RVU
  6. percent-of-charges, rate read from the NoChargeMasterFee schedule
Adjustments — all apply, in order
  1. Medicare multiple-procedure reduction — base codes 2, 3; pays 100/50% — when Modifier 55 is absent; Modifier 82 is absent
  2. Medicare multiple-endoscopy reduction
  3. Medicare multiple-radiology reduction — base codes 4
  4. Medicare bilateral-surgery adjustment
  5. mid-level provider reduction (by NUCC taxonomy)
  6. modifier 22 present → 135% of the running amount
  7. modifier 52 present → 50% of the running amount
  8. custom SQL — Same global-surgery post-op allocation as hash c5fd5754fcf4a52d (Allowed/GlobalDays*PostOpRate), but hardened: falls back to returning {Allowed} unchanged when GLOB_DAYS or POST_OP is missing/non-numeric/zero instead of dividing by zero. — when Modifier 55 is present
  9. modifier 54 present → 80% of the running amount
  10. modifier 62 present → 62.5% of the running amount
  11. modifier 73 present → 50% of the running amount
  12. modifier 78 present → 70% of the running amount
  13. modifier 80 present → 16% of the running amount
  14. modifier 81 present → 16% of the running amount
  15. modifier 82 present → 16% of the running amount
  16. modifier AS present → 14% of the running amount
  17. modifier QY present → 50% of the running amount
  18. modifier QK present → 50% of the running amount
  19. modifier QX present → 50% of the running amount
  20. cap each charge and the account total at 100% of billed charges
Cigna-VA-ASC · no contract map3 base · 20 adj
no contract map — cannot be resolved
Base terms — first match wins
  1. flat $0 — when NoncoverageStatus Noncovered is present
  2. 100% of the Fixed-Fees fee schedule
  3. 50% of Medicare ASC
Adjustments — all apply, in order
  1. Medicare multiple-procedure reduction — base codes 2, 3; pays 100/50% — when Modifier 55 is absent
  2. Medicare multiple-endoscopy reduction
  3. Medicare multiple-radiology reduction — base codes 4
  4. Medicare bilateral-surgery adjustment
  5. mid-level provider reduction (by NUCC taxonomy)
  6. modifier 22 present → 135% of the running amount
  7. modifier 52 present → 50% of the running amount
  8. custom SQL — Same global-surgery post-op allocation as hash c5fd5754fcf4a52d (Allowed/GlobalDays*PostOpRate), but hardened: falls back to returning {Allowed} unchanged when GLOB_DAYS or POST_OP is missing/non-numeric/zero instead of dividing by zero. — when Modifier 55 is present
  9. modifier 54 present → 80% of the running amount
  10. modifier 62 present → 62.5% of the running amount
  11. modifier 73 present → 50% of the running amount
  12. modifier 78 present → 70% of the running amount
  13. modifier 80 present → 16% of the running amount
  14. modifier 81 present → 16% of the running amount
  15. modifier 82 present → 16% of the running amount
  16. modifier AS present → 14% of the running amount
  17. modifier QY present → 50% of the running amount
  18. modifier QK present → 50% of the running amount
  19. modifier QX present → 50% of the running amount
  20. cap each charge and the account total at 100% of billed charges
Ohio-Anthem Commercial Profees - Old · no contract map3 base · 21 adj
no contract map — cannot be resolved
Base terms — first match wins
  1. flat $0 — when NoncoverageStatus Noncovered is present
  2. 100% of Medicare drug
  3. custom SQL — Ohio Anthem professional fee: resolves the facility's city (via zip->CBSA lookup) to pick among six Ohio-region-specific Anthem profee schedules (base/Cincinnati/Dayton/Toledo, each CEI vs non-CEI variant), then returns the facility- or office-rate for the procedure/modifier.
Adjustments — all apply, in order
  1. Medicare multiple-procedure reduction — base codes 2, 3; pays 100/50% — when Modifier 55 is absent; Modifier 82 is absent
  2. Medicare multiple-ophthalmology reduction — base codes 7; pays 100/80%
  3. Medicare multiple-endoscopy reduction
  4. Medicare multiple-radiology reduction — base codes 4
  5. Medicare bilateral-surgery adjustment
  6. mid-level provider reduction (by NUCC taxonomy)
  7. modifier 22 present → 135% of the running amount
  8. modifier 52 present → 50% of the running amount
  9. custom SQL — Same global-surgery post-op allocation as hash c5fd5754fcf4a52d (Allowed/GlobalDays*PostOpRate), but hardened: falls back to returning {Allowed} unchanged when GLOB_DAYS or POST_OP is missing/non-numeric/zero instead of dividing by zero. — when Modifier 55 is present
  10. modifier 54 present → 80% of the running amount
  11. modifier 62 present → 62.5% of the running amount
  12. modifier 73 present → 50% of the running amount
  13. modifier 78 present → 70% of the running amount
  14. modifier 80 present → 16% of the running amount
  15. modifier 81 present → 16% of the running amount
  16. modifier 82 present → 16% of the running amount
  17. modifier AS present → 14% of the running amount
  18. modifier QY present → 50% of the running amount
  19. modifier QK present → 50% of the running amount
  20. modifier QX present → 50% of the running amount
  21. cap each charge and the account total at 100% of billed charges
StilesEyecare-Aetna-Profee · no contract map3 base · 20 adj
no contract map — cannot be resolved
Base terms — first match wins
  1. flat $0 — when NoncoverageStatus Noncovered is present
  2. 100% of Medicare drug
  3. 100% of the Profee-Fees fee schedule
Adjustments — all apply, in order
  1. Medicare multiple-procedure reduction — base codes 2, 3; pays 100/50% — when Modifier 55 is absent; Modifier 82 is absent
  2. Medicare multiple-endoscopy reduction
  3. Medicare multiple-radiology reduction — base codes 4
  4. Medicare bilateral-surgery adjustment
  5. mid-level provider reduction (by NUCC taxonomy)
  6. modifier 22 present → 135% of the running amount
  7. modifier 52 present → 50% of the running amount
  8. custom SQL — Same global-surgery post-op allocation as hash c5fd5754fcf4a52d (Allowed/GlobalDays*PostOpRate), but hardened: falls back to returning {Allowed} unchanged when GLOB_DAYS or POST_OP is missing/non-numeric/zero instead of dividing by zero. — when Modifier 55 is present
  9. modifier 54 present → 80% of the running amount
  10. modifier 62 present → 62.5% of the running amount
  11. modifier 73 present → 50% of the running amount
  12. modifier 78 present → 70% of the running amount
  13. modifier 80 present → 16% of the running amount
  14. modifier 81 present → 16% of the running amount
  15. modifier 82 present → 16% of the running amount
  16. modifier AS present → 14% of the running amount
  17. modifier QY present → 50% of the running amount
  18. modifier QK present → 50% of the running amount
  19. modifier QX present → 50% of the running amount
  20. cap each charge and the account total at 100% of billed charges