Customer detail

EyeSouth

54
live contracts
13
cannot fire
19
calc types
17
SQL bodies
9
of those blocked
0
map conflicts

Methodology mix

ModifierAdjustment154
PercentOfFees129
MultipleProcedureAdjustment60
LesserOfAdjustment51
ChargeLevelSqlAdjustment35
SqlExpression28
CalculationBuilder20
FlatPercentOfCharges18
PercentOfCharges17
MedicareLab15
MedicareDrug15
MedicareRVU15
MedicareDME15
PercentageAdjustment11
MultipleEndoscopyAdjustment5
MedicareMultipleEndoscopyAdjustment5
MedicareMultipleRadiologyAdjustment5
MedicareMultipleProcedureAdjustment5
MidLevelProviderAdjustment5

Contracts

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

Aetna3 base · 1 adj
Aetna HPN
Profee · 6 named facilities · 2020-07-01 → 2099-12-31
Aetna/Coventry EHN HMO
Profee · 6 named facilities · 2020-07-01 → 2099-12-31
Base terms — first match wins
  1. 100% of the Non-Covered fee schedule
  2. custom SQL — Prices an ophthalmology charge from a customer-specific per-unit fee schedule keyed by insurance, procedure code, whether the '26' (professional-component) modifier is present, place-of-service (facility vs non-facility), and whether the billing provider is classified OD or MD, times units.
  3. custom SQL — Percent-of-charges pricing for optometry/ophthalmology services keyed by facility type (in/out of hospital), modifier (26 vs not), procedure code, and the billing provider's type (Optometrist->OD vs Ophthalmology/other->MD): Amount = Charged * (Percent/100).
Adjustments — all apply, in order
  1. multiple-procedure reduction (contract rules) — base codes 2, 3; pays 100/50%
Aetna-EHN3 base · 1 adj
Aetna/Coventry EHN PPO
Profee · all facilities · 2020-07-01 → 2099-12-31
Base terms — first match wins
  1. 100% of the Non-Covered fee schedule
  2. custom SQL — Prices a charge from Emory's own supplemental fee schedule, keyed by insurance, TC/26 modifier, procedure code, a collapsed provider-type dimension (Optometrist->OD, else MD), and a facility-vs-clinic flag, then multiplies by units.
  3. custom SQL — Looks up a percentage (not a dollar fee) from an Emory-specific fee-schedule table keyed by insurance, TC/26 modifier, procedure code, billing-provider type (OD vs MD), and facility-vs-clinic flag, and applies it directly to the charge's billed amount.
Adjustments — all apply, in order
  1. multiple-procedure reduction (contract rules) — base codes 2, 3; pays 100/50%
Aetna-FEMI-Profee3 base · 3 adj
Aetna
Profee · 964541 · 2022-01-01 → 2999-12-31
Base terms — first match wins
  1. 100% of the Non-Covered fee schedule
  2. 100% of the Profee-Fees fee schedule
  3. 100% of the Fixed-Fees fee schedule
Adjustments — all apply, in order
  1. multiple-procedure reduction (contract rules) — base codes 2; pays 100/50%
  2. custom SQL — For charges flagged with a custom 'ML' (manual-limit) code = 'Yes', applies a flat 15% reduction (Allowed*0.85) unless the charge carries modifier TC/AS or its code falls in one of several excluded ranges/patterns (alpha-prefixed codes, 95xxx, lab 80047-89398, radiology 70010-79999, immunization 90281-90470/90475-90749, cardio 93000-93278).
  3. cap each charge and the account total at 100% of billed charges
Aetna-GAIN-Profee3 base · 4 adj
Aetna
Profee · 1-ESP001, 2-ESP001 · 2023-01-01 → 2999-12-31
Base terms — first match wins
  1. 100% of the Non-Covered fee schedule
  2. 100% of the Profee-Fees fee schedule
  3. percent-of-charges, rate read from the Profee-PoC schedule
Adjustments — all apply, in order
  1. multiple-procedure reduction (contract rules) — base codes 2; pays 100/50%
  2. custom SQL — For charges flagged with a custom 'ML' (manual-limit) code = 'Yes', applies a flat 15% reduction (Allowed*0.85) unless the charge carries modifier TC/AS or its code falls in one of several excluded ranges/patterns (alpha-prefixed codes, 95xxx, lab 80047-89398, radiology 70010-79999, immunization 90281-90470/90475-90749, cardio 93000-93278).
  3. modifier 50 present → 150% of the running amount
  4. cap each charge and the account total at 100% of billed charges
Aetna-MCOA-Profee2 base · 3 adj
Aetna
Profee · 2-MED001 · 2022-01-01 → 2999-12-31
Base terms — first match wins
  1. 100% of the Non-Covered fee schedule
  2. 100% of the Fixed-Fees fee schedule
Adjustments — all apply, in order
  1. multiple-procedure reduction (contract rules) — base codes 2; pays 100/50%
  2. custom SQL — For charges flagged with a custom 'ML' (manual-limit) code = 'Yes', applies a flat 15% reduction (Allowed*0.85) unless the charge carries modifier TC/AS or its code falls in one of several excluded ranges/patterns (alpha-prefixed codes, 95xxx, lab 80047-89398, radiology 70010-79999, immunization 90281-90470/90475-90749, cardio 93000-93278).
  3. cap each charge and the account total at 100% of billed charges
Aetna-Medicare-GAR-Facility5 base · 4 adj
Aetna Medicare
Facility · 2-GAR002, 1-GAR002 · 2022-01-01 → 2999-12-31
Base terms — first match wins
  1. 100% of the Non-Covered fee schedule
  2. 100% of Medicare RVU
  3. 100% of Medicare lab
  4. 100% of Medicare drug
  5. 100% of Medicare DME
Adjustments — all apply, in order
  1. modifier 50 present → 150% of the running amount
  2. multiple-procedure reduction (contract rules) — base codes 2; pays 100/50%
  3. rescale by a percentage read from the Mid-Level-Charges schedule — when IsMidLevel Yes is present
  4. cap each charge and the account total at 100% of billed charges
Aetna-Medicare-GAR-Profee5 base · 4 adj
Aetna Medicare
Profee · 2-GAR002 · 2022-01-01 → 2999-12-31
Base terms — first match wins
  1. 100% of the Non-Covered fee schedule
  2. 100% of Medicare RVU
  3. 100% of Medicare lab
  4. 100% of Medicare drug
  5. 100% of Medicare DME
Adjustments — all apply, in order
  1. modifier 50 present → 150% of the running amount
  2. multiple-procedure reduction (contract rules) — base codes 2; pays 100/50%
  3. rescale by a percentage read from the Mid-Level-Charges schedule — when IsMidLevel Yes is present
  4. cap each charge and the account total at 100% of billed charges
Aetna-Piedmont3 base · 1 adj
Aetna Piedmont
Profee · 964284, 964633, 1-ESP001, 2-ESP001, 964451, 3-NOR013, 2-NOR013, 3-ESP001 · 2020-01-01 → 2099-12-31
Base terms — first match wins
  1. 100% of the Non-Covered fee schedule
  2. 100% of the Fixed-Fees fee schedule
  3. custom SQL — Base allowed amount priced at 227% of a Medicare RVU-derived fee for the billed procedure, always computed using Atlanta (zip 30301) locality RVU data regardless of the patient's actual location, split by 26/TC modifier and clinic-vs-non-clinic facility type.
Adjustments — all apply, in order
  1. multiple-procedure reduction (contract rules) — base codes 2, 3; pays 100/50%
Aetna-Profee3 base · 4 adj
Aetna
Facility, Profee · 2-GAR002, 1-GAR002 · 2022-09-01 → 2999-12-31
Aetna
Facility, Profee · 13 named facilities · 2022-09-01 → 2999-12-31
Base terms — first match wins
  1. 100% of the Non-Covered fee schedule
  2. 100% of the Profee-Fees-FeePricingRecord fee schedule
  3. percent-of-charges, rate read from the Profee-PoC-FeePricingRecord schedule
Adjustments — all apply, in order
  1. multiple-procedure reduction (contract rules) — base codes 2; pays 100/50%
  2. custom SQL — For charges flagged with a custom 'ML' (manual-limit) code = 'Yes', applies a flat 15% reduction (Allowed*0.85) unless the charge carries modifier TC/AS or its code falls in one of several excluded ranges/patterns (alpha-prefixed codes, 95xxx, lab 80047-89398, radiology 70010-79999, immunization 90281-90470/90475-90749, cardio 93000-93278).
  3. modifier 50 present → 150% of the running amount
  4. cap each charge and the account total at 100% of billed charges
Ambetter-GAR-Profee3 base · 4 adj
Ambetter
Profee · 2-GAR002, 1-GAR002 · 2022-01-01 → 2999-12-31
Base terms — first match wins
  1. 100% of the Non-Covered fee schedule
  2. 100% of the Profee-Fees fee schedule
  3. percent-of-charges, rate read from the Profee-PoC schedule
Adjustments — all apply, in order
  1. multiple-procedure reduction (contract rules) — base codes 2; pays 100/50%
  2. custom SQL — For charges flagged with a custom 'ML' (manual-limit) code = 'Yes', applies a flat 15% reduction (Allowed*0.85) unless the charge carries modifier TC/AS or its code falls in one of several excluded ranges/patterns (alpha-prefixed codes, 95xxx, lab 80047-89398, radiology 70010-79999, immunization 90281-90470/90475-90749, cardio 93000-93278).
  3. modifier 50 present → 150% of the running amount
  4. cap each charge and the account total at 100% of billed charges
BCBS-AL-Profee2 base · 4 adj
BCBS AL
Profee · 964562 · 2021-12-01 → 2999-12-31
Base terms — first match wins
  1. 100% of the Non-Covered fee schedule
  2. 100% of the Profee-Fees fee schedule
Adjustments — all apply, in order
  1. multiple-procedure reduction (contract rules) — base codes 2; pays 100/50%
  2. custom SQL — For charges flagged with a custom 'ML' (manual-limit) code = 'Yes', applies a flat 15% reduction (Allowed*0.85) unless the charge carries modifier TC/AS or its code falls in one of several excluded ranges/patterns (alpha-prefixed codes, 95xxx, lab 80047-89398, radiology 70010-79999, immunization 90281-90470/90475-90749, cardio 93000-93278).
  3. modifier 50 present → 150% of the running amount
  4. cap each charge and the account total at 100% of billed charges
BCBS-EHN3 base · 1 adj
BCBS EHN HMO, BCBS EHN PPO, BCBS Pathway
Profee · all facilities · 2020-07-01 → 2099-12-31
Base terms — first match wins
  1. 100% of the Non-Covered fee schedule
  2. custom SQL — Emory/BCBS profee schedule fee keyed by BCBS region (via a region crosswalk, with a hardcoded 'BCBS Pathway' override), provider type (MD vs OD), facility vs non-facility, modifier (26/TC), and procedure code.
  3. custom SQL — Emory Healthcare Network BCBS pricing: resolves facility type, provider type (MD vs OD for ophthalmology/optometry), and a BCBS 'region' (overridden to 'Atlanta' for BCBS Pathway plans) from TransformEHNBCBSRegionMap, then applies a percent-of-charge rate looked up from SourceEmoryFeeScheduleBCBSPoc keyed on insurance/modifier/procedure/provider-type/facility/region.
Adjustments — all apply, in order
  1. multiple-procedure reduction (contract rules) — base codes 2, 3; pays 100/50%
BCBS-FL-Profee3 base · 4 adj
BCBS FL NetworkBlue, BCBS FL PPC, BCBS FL PPS
Profee · 964541 · 2021-10-01 → 2999-12-31
Base terms — first match wins
  1. 100% of the Non-Covered fee schedule
  2. 100% of the Profee-Fees-Secondary fee schedule — when ProviderType Ophthalmology is present; IsPediatricAge 1 is present
  3. 100% of the Profee-Fees fee schedule
Adjustments — all apply, in order
  1. multiple-procedure reduction (contract rules) — base codes 2; pays 100/50%
  2. custom SQL — For charges flagged with a custom 'ML' (manual-limit) code = 'Yes', applies a flat 15% reduction (Allowed*0.85) unless the charge carries modifier TC/AS or its code falls in one of several excluded ranges/patterns (alpha-prefixed codes, 95xxx, lab 80047-89398, radiology 70010-79999, immunization 90281-90470/90475-90749, cardio 93000-93278).
  3. modifier 50 present → 150% of the running amount
  4. cap each charge and the account total at 100% of billed charges
BCBS-GA-Clayton-Profee3 base · 4 adj
BCBS GA HMO, BCBS GA PPO
Profee · 14 named facilities · 2022-01-01 → 2999-12-31
Base terms — first match wins
  1. 100% of the Non-Covered fee schedule
  2. 100% of the Profee-Fees fee schedule
  3. percent-of-charges, rate read from the Profee-PoC schedule
Adjustments — all apply, in order
  1. multiple-procedure reduction (contract rules) — base codes 2; pays 100/50%
  2. custom SQL — For charges flagged with a custom 'ML' (manual-limit) code = 'Yes', applies a flat 15% reduction (Allowed*0.85) unless the charge carries modifier TC/AS or its code falls in one of several excluded ranges/patterns (alpha-prefixed codes, 95xxx, lab 80047-89398, radiology 70010-79999, immunization 90281-90470/90475-90749, cardio 93000-93278).
  3. modifier 50 present → 150% of the running amount
  4. cap each charge and the account total at 100% of billed charges
BCBS-GA-Facility8 base · 4 adj
BCBS GA HMO, BCBS GA PAR, BCBS GA PPO
Facility · 2-GAR002, 1-GAR002 · 2020-06-01 → 2023-04-16
Base terms — first match wins
  1. 100% of the Non-Covered fee schedule
  2. 100% of the Fixed-Fees fee schedule
  3. 100% of the Outpatient-Grouper-BCBSGA fee schedule
  4. 100% of the Outpatient-Grouper-BCBSGA fee schedule
  5. 100% of the Outpatient-Grouper-BCBSGA fee schedule
  6. 55% of billed charges
  7. 60% of billed charges
  8. 50% of billed charges
Adjustments — all apply, in order
  1. multiple-procedure reduction (contract rules) — base codes 2; pays 100/50/25%
  2. custom SQL — For charges flagged with a custom 'ML' (manual-limit) code = 'Yes', applies a flat 15% reduction (Allowed*0.85) unless the charge carries modifier TC/AS or its code falls in one of several excluded ranges/patterns (alpha-prefixed codes, 95xxx, lab 80047-89398, radiology 70010-79999, immunization 90281-90470/90475-90749, cardio 93000-93278).
  3. modifier 50 present → 150% of the running amount
  4. cap each charge and the account total at 100% of billed charges
BCBS-GA-Facility-GAR-04-20235 base · 4 adj
BCBS GA HMO, BCBS GA PAR, BCBS GA PPO
Facility · 2-GAR002, 1-GAR002 · 2023-04-17 → 2999-12-31
Base terms — first match wins
  1. 100% of Medicare RVU
  2. 100% of Medicare lab
  3. 100% of Medicare DME
  4. 100% of the Medicare-APC fee schedule
  5. 50% of billed charges
Adjustments — all apply, in order
  1. multiple-procedure reduction (contract rules) — base codes 2; pays 100/50%
  2. custom SQL — For charges flagged with a custom 'ML' (manual-limit) code = 'Yes', applies a flat 15% reduction (Allowed*0.85) unless the charge carries modifier TC/AS or its code falls in one of several excluded ranges/patterns (alpha-prefixed codes, 95xxx, lab 80047-89398, radiology 70010-79999, immunization 90281-90470/90475-90749, cardio 93000-93278).
  3. modifier 50 present → 150% of the running amount
  4. cap each charge and the account total at 100% of billed charges
BCBS-GA-GAIN-HMO-Profee3 base · 4 adj
BCBS GA HMO
Profee · 1-ESP001, 2-ESP001 · 2023-01-01 → 2999-12-31
Base terms — first match wins
  1. 100% of the Non-Covered fee schedule
  2. 100% of the Profee-Fees fee schedule
  3. percent-of-charges, rate read from the Profee-PoC schedule
Adjustments — all apply, in order
  1. multiple-procedure reduction (contract rules) — base codes 2; pays 100/50%
  2. custom SQL — For charges flagged with a custom 'ML' (manual-limit) code = 'Yes', applies a flat 15% reduction (Allowed*0.85) unless the charge carries modifier TC/AS or its code falls in one of several excluded ranges/patterns (alpha-prefixed codes, 95xxx, lab 80047-89398, radiology 70010-79999, immunization 90281-90470/90475-90749, cardio 93000-93278).
  3. modifier 50 present → 150% of the running amount
  4. cap each charge and the account total at 100% of billed charges
BCBS-GA-GAIN-PPO-Profee3 base · 4 adj
BCBS GA PPO
Profee · 1-ESP001, 2-ESP001 · 2023-01-01 → 2999-12-31
Base terms — first match wins
  1. 100% of the Non-Covered fee schedule
  2. 100% of the Profee-Fees fee schedule
  3. percent-of-charges, rate read from the Profee-PoC schedule
Adjustments — all apply, in order
  1. multiple-procedure reduction (contract rules) — base codes 2; pays 100/50%
  2. custom SQL — For charges flagged with a custom 'ML' (manual-limit) code = 'Yes', applies a flat 15% reduction (Allowed*0.85) unless the charge carries modifier TC/AS or its code falls in one of several excluded ranges/patterns (alpha-prefixed codes, 95xxx, lab 80047-89398, radiology 70010-79999, immunization 90281-90470/90475-90749, cardio 93000-93278).
  3. modifier 50 present → 150% of the running amount
  4. cap each charge and the account total at 100% of billed charges
BCBS-GA-GEP-Profee3 base · 4 adj
BCBS GA HMO, BCBS GA PPO
Profee · 12 named facilities · 2022-01-01 → 2999-12-31
Base terms — first match wins
  1. 100% of the Non-Covered fee schedule
  2. 100% of the Profee-Fees fee schedule
  3. percent-of-charges, rate read from the Profee-PoC schedule
Adjustments — all apply, in order
  1. multiple-procedure reduction (contract rules) — base codes 2; pays 100/50%
  2. custom SQL — For charges flagged with a custom 'ML' (manual-limit) code = 'Yes', applies a flat 15% reduction (Allowed*0.85) unless the charge carries modifier TC/AS or its code falls in one of several excluded ranges/patterns (alpha-prefixed codes, 95xxx, lab 80047-89398, radiology 70010-79999, immunization 90281-90470/90475-90749, cardio 93000-93278).
  3. modifier 50 present → 150% of the running amount
  4. cap each charge and the account total at 100% of billed charges
BCBS-GA-Medicare-GAR-Facility5 base · 4 adj
BCBS Medicare GA
Facility · 2-GAR002, 1-GAR002 · 2020-06-01 → 2999-12-31
Base terms — first match wins
  1. 100% of the Non-Covered fee schedule
  2. 100% of Medicare RVU
  3. 100% of Medicare lab
  4. 100% of Medicare drug
  5. 100% of Medicare DME
Adjustments — all apply, in order
  1. modifier 50 present → 150% of the running amount
  2. multiple-procedure reduction (contract rules) — base codes 2; pays 100/50%
  3. rescale by a percentage read from the Mid-Level-Charges schedule — when IsMidLevel Yes is present
  4. cap each charge and the account total at 100% of billed charges
BCBS-GA-Medicare-GAR-Profee5 base · 4 adj
BCBS Medicare GA
Profee · 2-GAR002 · 2022-01-01 → 2999-12-31
Base terms — first match wins
  1. 100% of the Non-Covered fee schedule
  2. 100% of Medicare RVU
  3. 100% of Medicare lab
  4. 100% of Medicare drug
  5. 100% of Medicare DME
Adjustments — all apply, in order
  1. modifier 50 present → 150% of the running amount
  2. multiple-procedure reduction (contract rules) — base codes 2; pays 100/50%
  3. rescale by a percentage read from the Mid-Level-Charges schedule — when IsMidLevel Yes is present
  4. cap each charge and the account total at 100% of billed charges
BCBS-GA-Piedmont-Profee3 base · 4 adj
BCBS GA HMO, BCBS GA PPO
Profee · 14 named facilities · 2022-04-01 → 2024-03-31
Base terms — first match wins
  1. 100% of the Non-Covered fee schedule
  2. 100% of the Profee-Fees fee schedule
  3. percent-of-charges, rate read from the Profee-PoC schedule
Adjustments — all apply, in order
  1. multiple-procedure reduction (contract rules) — base codes 2; pays 100/50%
  2. custom SQL — For charges flagged with a custom 'ML' (manual-limit) code = 'Yes', applies a flat 15% reduction (Allowed*0.85) unless the charge carries modifier TC/AS or its code falls in one of several excluded ranges/patterns (alpha-prefixed codes, 95xxx, lab 80047-89398, radiology 70010-79999, immunization 90281-90470/90475-90749, cardio 93000-93278).
  3. modifier 50 present → 150% of the running amount
  4. cap each charge and the account total at 100% of billed charges
BCBS-GA-Piedmont-Profee-01-01-20243 base · 4 adj
BCBS GA HMO, BCBS GA PPO
Profee · 3-ESP001 · 2024-04-01 → 2999-12-31
Base terms — first match wins
  1. 100% of the Non-Covered fee schedule
  2. 100% of the Profee-Fees-FeePricingRecord fee schedule
  3. percent-of-charges, rate read from the Profee-PoC schedule
Adjustments — all apply, in order
  1. multiple-procedure reduction (contract rules) — base codes 2; pays 100/50%
  2. custom SQL — For charges flagged with a custom 'ML' (manual-limit) code = 'Yes', applies a flat 15% reduction (Allowed*0.85) unless the charge carries modifier TC/AS or its code falls in one of several excluded ranges/patterns (alpha-prefixed codes, 95xxx, lab 80047-89398, radiology 70010-79999, immunization 90281-90470/90475-90749, cardio 93000-93278).
  3. modifier 50 present → 150% of the running amount
  4. cap each charge and the account total at 100% of billed charges
BCBS-GA-Profee3 base · 4 adj
BCBS GA HMO, BCBS GA PPO
Profee · 2-GAR002, 1-GAR002 · 2022-01-01 → 2999-12-31
Base terms — first match wins
  1. 100% of the Non-Covered fee schedule
  2. 100% of Medicare drug
  3. 100% of the Profee-Fees fee schedule
Adjustments — all apply, in order
  1. multiple-procedure reduction (contract rules) — base codes 2; pays 100/50/25%
  2. custom SQL — For charges flagged with a custom 'ML' (manual-limit) code = 'Yes', applies a flat 15% reduction (Allowed*0.85) unless the charge carries modifier TC/AS or its code falls in one of several excluded ranges/patterns (alpha-prefixed codes, 95xxx, lab 80047-89398, radiology 70010-79999, immunization 90281-90470/90475-90749, cardio 93000-93278).
  3. modifier 50 present → 150% of the running amount
  4. cap each charge and the account total at 100% of billed charges
BCBS-LA-Facility4 base · 4 adj
BCBS LA HMO, BCBS LA PPO
Facility · 5-ESP001 · 2006-08-01 → 2999-12-31
Base terms — first match wins
  1. 100% of the Non-Covered fee schedule
  2. 100% of the Outpatient-Grouper-BCBSLA fee schedule
  3. 70% of billed charges
  4. 60% of billed charges
Adjustments — all apply, in order
  1. multiple-procedure reduction (contract rules) — base codes 2; pays 100/50%
  2. custom SQL — For charges flagged with a custom 'ML' (manual-limit) code = 'Yes', applies a flat 15% reduction (Allowed*0.85) unless the charge carries modifier TC/AS or its code falls in one of several excluded ranges/patterns (alpha-prefixed codes, 95xxx, lab 80047-89398, radiology 70010-79999, immunization 90281-90470/90475-90749, cardio 93000-93278).
  3. modifier 50 present → 150% of the running amount
  4. cap each charge and the account total at 100% of billed charges
BCBS-LA-Profee2 base · 4 adj
BCBS LA HMO, BCBS LA PPO, BCBS LA Traditional
Profee · 5-ESP001 · 2010-06-09 → 2999-12-31
Base terms — first match wins
  1. 100% of the Non-Covered fee schedule
  2. 100% of the Profee-Fees fee schedule
Adjustments — all apply, in order
  1. multiple-procedure reduction (contract rules) — base codes 2; pays 100/50%
  2. custom SQL — For charges flagged with a custom 'ML' (manual-limit) code = 'Yes', applies a flat 15% reduction (Allowed*0.85) unless the charge carries modifier TC/AS or its code falls in one of several excluded ranges/patterns (alpha-prefixed codes, 95xxx, lab 80047-89398, radiology 70010-79999, immunization 90281-90470/90475-90749, cardio 93000-93278).
  3. modifier 50 present → 150% of the running amount
  4. cap each charge and the account total at 100% of billed charges
BCBS-OH-MWEC-Facility3 base · 3 adj
BCBS OH
Facility · 4-MID005, 3-MID005, 2-MID005 · 2023-01-01 → 2024-02-29
Base terms — first match wins
  1. 100% of the Fixed-Fees-Carveout fee schedule
  2. 100% of the Outpatient-Grouper fee schedule
  3. 100% of billed charges ⚠︎ named “70% of Billed Charges” but configured at 100%
Adjustments — all apply, in order
  1. custom SQL — For charges flagged with a custom 'ML' (manual-limit) code = 'Yes', applies a flat 15% reduction (Allowed*0.85) unless the charge carries modifier TC/AS or its code falls in one of several excluded ranges/patterns (alpha-prefixed codes, 95xxx, lab 80047-89398, radiology 70010-79999, immunization 90281-90470/90475-90749, cardio 93000-93278).
  2. modifier 50 present → 150% of the running amount
  3. cap each charge and the account total at 100% of billed charges
BCBS-OH-MWEC-Facility-3-1-20243 base · 4 adj
BCBS OH
Facility · 4-MID005, 3-MID005, 2-MID005 · 2024-03-01 → 2999-12-31
Base terms — first match wins
  1. 100% of the Fixed-Fees-Carveout fee schedule
  2. 100% of the Outpatient-Grouper fee schedule
  3. 100% of billed charges ⚠︎ named “70% of Billed Charges” but configured at 100%
Adjustments — all apply, in order
  1. custom SQL — For charges flagged with a custom 'ML' (manual-limit) code = 'Yes', applies a flat 15% reduction (Allowed*0.85) unless the charge carries modifier TC/AS or its code falls in one of several excluded ranges/patterns (alpha-prefixed codes, 95xxx, lab 80047-89398, radiology 70010-79999, immunization 90281-90470/90475-90749, cardio 93000-93278).
  2. multiple-procedure reduction (contract rules) — base codes 2; pays 100/25/0%
  3. modifier 50 present → 150% of the running amount
  4. cap each charge and the account total at 100% of billed charges
BCBS-OH-MWEC-Profee1 base · 4 adj
BCBS OH
Profee · 4-MID005, 3-MID005, 2-MID005 · 2023-01-01 → 2999-12-31
Base terms — first match wins
  1. 100% of the Profee-Fees fee schedule
Adjustments — all apply, in order
  1. multiple-procedure reduction (contract rules) — base codes 2; pays 100/50%
  2. custom SQL — For charges flagged with a custom 'ML' (manual-limit) code = 'Yes', applies a flat 15% reduction (Allowed*0.85) unless the charge carries modifier TC/AS or its code falls in one of several excluded ranges/patterns (alpha-prefixed codes, 95xxx, lab 80047-89398, radiology 70010-79999, immunization 90281-90470/90475-90749, cardio 93000-93278).
  3. modifier 50 present → 150% of the running amount
  4. cap each charge and the account total at 100% of billed charges
BCBS-Piedmont2 base · 1 adj
BCBS HMO Piedmont, BCBS PPO Piedmont
Profee · 964284, 964633, 1-ESP001, 2-ESP001, 964451, 3-NOR013, 2-NOR013, 3-ESP001 · 2020-01-01 → 2099-12-31
Base terms — first match wins
  1. 100% of the Non-Covered fee schedule
  2. 100% of the Fixed-Fees fee schedule
Adjustments — all apply, in order
  1. multiple-procedure reduction (contract rules) — base codes 2, 3; pays 100/50%
BCBS-TN-Facility2 base · 4 adj
BCBS TN BlueCare, BCBS TN Network P, BCBS TN Network S
Facility · 963831, 963614 · 2004-01-01 → 2999-12-31
Base terms — first match wins
  1. 100% of the Non-Covered fee schedule
  2. 100% of the Outpatient-Grouper-BCBSTN fee schedule
Adjustments — all apply, in order
  1. multiple-procedure reduction (contract rules) — base codes 2; pays 100/50/50%
  2. custom SQL — For charges flagged with a custom 'ML' (manual-limit) code = 'Yes', applies a flat 15% reduction (Allowed*0.85) unless the charge carries modifier TC/AS or its code falls in one of several excluded ranges/patterns (alpha-prefixed codes, 95xxx, lab 80047-89398, radiology 70010-79999, immunization 90281-90470/90475-90749, cardio 93000-93278).
  3. modifier 50 present → 150% of the running amount
  4. cap each charge and the account total at 100% of billed charges
Charges1 base · 0 adj
Charges
Profee · all facilities · 2020-07-01 → 2099-12-31
Base terms — first match wins
  1. custom SQL — Straight lookup of the customer's own charge-master list price by charge code and effective-date range -- effectively billed-charge-equals-allowed-amount.
Cigna-EHN3 base · 1 adj
Cigna EHN HMO, Cigna EHN PPO, Cigna Healthspring EHN
Profee · all facilities · 2020-07-01 → 2099-12-31
Base terms — first match wins
  1. 100% of the Non-Covered fee schedule
  2. custom SQL — Prices a charge from Emory's own supplemental fee schedule, keyed by insurance, TC/26 modifier, procedure code, a collapsed provider-type dimension (Optometrist->OD, else MD), and a facility-vs-clinic flag, then multiplies by units.
  3. custom SQL — Looks up a percentage (not a dollar fee) from an Emory-specific fee-schedule table keyed by insurance, TC/26 modifier, procedure code, billing-provider type (OD vs MD), and facility-vs-clinic flag, and applies it directly to the charge's billed amount.
Adjustments — all apply, in order
  1. multiple-procedure reduction (contract rules) — base codes 2, 3; pays 100/50%
Cigna-GAR-Profee3 base · 4 adj
Cigna
Profee · 2-GAR002, 1-GAR002 · 2021-09-01 → 2999-12-31
Base terms — first match wins
  1. 100% of the Non-Covered fee schedule
  2. 100% of the Profee-Fees fee schedule
  3. percent-of-charges, rate read from the Profee-PoC schedule
Adjustments — all apply, in order
  1. multiple-procedure reduction (contract rules) — base codes 2; pays 100/50%
  2. custom SQL — For charges flagged with a custom 'ML' (manual-limit) code = 'Yes', applies a flat 15% reduction (Allowed*0.85) unless the charge carries modifier TC/AS or its code falls in one of several excluded ranges/patterns (alpha-prefixed codes, 95xxx, lab 80047-89398, radiology 70010-79999, immunization 90281-90470/90475-90749, cardio 93000-93278).
  3. modifier 50 present → 150% of the running amount
  4. cap each charge and the account total at 100% of billed charges
Cigna-GEP-Profee3 base · 4 adj
Cigna
Profee · 13 named facilities · 2022-09-01 → 2999-12-31
Base terms — first match wins
  1. 100% of the Non-Covered fee schedule
  2. 100% of the Profee-Fees-FeePricingRecord fee schedule
  3. percent-of-charges, rate read from the Profee-PoC-FeePricingRecord schedule
Adjustments — all apply, in order
  1. multiple-procedure reduction (contract rules) — base codes 2; pays 100/50%
  2. custom SQL — For charges flagged with a custom 'ML' (manual-limit) code = 'Yes', applies a flat 15% reduction (Allowed*0.85) unless the charge carries modifier TC/AS or its code falls in one of several excluded ranges/patterns (alpha-prefixed codes, 95xxx, lab 80047-89398, radiology 70010-79999, immunization 90281-90470/90475-90749, cardio 93000-93278).
  3. modifier 50 present → 150% of the running amount
  4. cap each charge and the account total at 100% of billed charges
Cigna-Piedmont3 base · 1 adj
Cigna IFP Piedmont, Cigna Piedmont
Profee · 964284, 964633, 1-ESP001, 2-ESP001, 964451, 3-NOR013, 2-NOR013, 3-ESP001 · 2020-01-01 → 2099-12-31
Base terms — first match wins
  1. 100% of the Non-Covered fee schedule
  2. 100% of the Fixed-Fees fee schedule
  3. 50% of billed charges
Adjustments — all apply, in order
  1. multiple-procedure reduction (contract rules) — base codes 2, 3; pays 100/50%
Humana-EHN3 base · 1 adj
Humana EHN HMO, Humana EHN PPO
Profee · all facilities · 2020-07-01 → 2099-12-31
Base terms — first match wins
  1. 100% of the Non-Covered fee schedule
  2. custom SQL — Prices a charge from Emory's own supplemental fee schedule, keyed by insurance, TC/26 modifier, procedure code, a collapsed provider-type dimension (Optometrist->OD, else MD), and a facility-vs-clinic flag, then multiplies by units.
  3. custom SQL — Looks up a percentage (not a dollar fee) from an Emory-specific fee-schedule table keyed by insurance, TC/26 modifier, procedure code, billing-provider type (OD vs MD), and facility-vs-clinic flag, and applies it directly to the charge's billed amount.
Adjustments — all apply, in order
  1. multiple-procedure reduction (contract rules) — base codes 2, 3; pays 100/50%
Humana-GAR-Profee3 base · 4 adj
Humana
Profee · 2-GAR002, 1-GAR002 · 2021-09-01 → 2999-12-31
Base terms — first match wins
  1. 100% of the Non-Covered fee schedule
  2. 100% of the Profee-Fees fee schedule
  3. percent-of-charges, rate read from the Profee-PoC schedule
Adjustments — all apply, in order
  1. multiple-procedure reduction (contract rules) — base codes 2; pays 100/50%
  2. custom SQL — For charges flagged with a custom 'ML' (manual-limit) code = 'Yes', applies a flat 15% reduction (Allowed*0.85) unless the charge carries modifier TC/AS or its code falls in one of several excluded ranges/patterns (alpha-prefixed codes, 95xxx, lab 80047-89398, radiology 70010-79999, immunization 90281-90470/90475-90749, cardio 93000-93278).
  3. modifier 50 present → 150% of the running amount
  4. cap each charge and the account total at 100% of billed charges
Humana-Medicare-GAR-Facility5 base · 4 adj
Humana Medicare
Facility · 2-GAR002, 1-GAR002 · 2022-01-01 → 2999-12-31
Base terms — first match wins
  1. 100% of the Non-Covered fee schedule
  2. 102% of Medicare RVU
  3. 102% of Medicare lab
  4. 102% of Medicare drug
  5. 102% of Medicare DME
Adjustments — all apply, in order
  1. modifier 50 present → 150% of the running amount
  2. multiple-procedure reduction (contract rules) — base codes 2; pays 100/50%
  3. rescale by a percentage read from the Mid-Level-Charges schedule — when IsMidLevel Yes is present
  4. cap each charge and the account total at 100% of billed charges
Humana-Medicare-GAR-Profee5 base · 4 adj
Humana Medicare
Profee · 2-GAR002 · 2022-01-01 → 2999-12-31
Base terms — first match wins
  1. 100% of the Non-Covered fee schedule
  2. 102% of Medicare RVU
  3. 102% of Medicare lab
  4. 102% of Medicare drug
  5. 102% of Medicare DME
Adjustments — all apply, in order
  1. modifier 50 present → 150% of the running amount
  2. multiple-procedure reduction (contract rules) — base codes 2; pays 100/50%
  3. rescale by a percentage read from the Mid-Level-Charges schedule — when IsMidLevel Yes is present
  4. cap each charge and the account total at 100% of billed charges
Humana-Piedmont2 base · 1 adj
Humana Piedmont HMO, Humana Piedmont PPO
Profee · 964284, 964633, 1-ESP001, 2-ESP001, 964451, 3-NOR013, 2-NOR013, 3-ESP001 · 2020-01-01 → 2099-12-31
Base terms — first match wins
  1. 100% of the Non-Covered fee schedule
  2. 100% of the Fixed-Fees fee schedule
Adjustments — all apply, in order
  1. multiple-procedure reduction (contract rules) — base codes 2, 3; pays 100/50%
Medicare-Profee5 base · 13 adj
Medicare, MedicareScenario
Facility, Optical, Profee · all facilities · 2018-01-01 → 2999-12-31
Base terms — first match wins
  1. 100% of the Non-Covered fee schedule
  2. 100% of Medicare RVU
  3. 100% of Medicare lab
  4. 100% of Medicare drug
  5. 100% of Medicare DME
Adjustments — all apply, in order
  1. multiple-endoscopy reduction (contract rules)
  2. modifier 50 present → 150% of the running amount
  3. multiple-procedure reduction (contract rules) — base codes 2; pays 100/50%
  4. rescale by a percentage read from the Mid-Level-Charges schedule — when IsMidLevel Yes is present
  5. modifier 22 present → 135% of the running amount
  6. modifier 52 present → 90% of the running amount
  7. modifier 62 present → 62.5% of the running amount
  8. modifier 80 present → 16% of the running amount
  9. modifier 81 present → 16% of the running amount
  10. modifier 82 present → 16% of the running amount
  11. modifier AS present → 13.6% of the running amount
  12. modifier 78 present → 69% of the running amount
  13. cap each charge and the account total at 100% of billed charges
Medicare-Profee-BCBS-Piedmont4 base · 13 adj
BCBS Piedmont Medicare GA
Profee · 964284, 964633, 1-ESP001, 2-ESP001, 964451, 3-NOR013, 2-NOR013, 3-ESP001 · 2020-07-01 → 2099-12-31
Base terms — first match wins
  1. 100% of the Non-Covered fee schedule
  2. custom SQL — Medicare RVU-based fee via a shared CommonData RVU function (OPPS-adjusted, first-sequence value for the code/zip/facility-type), times units, bumped up 4%.
  3. custom SQL — 104% of the national Medicare Average Sales Price (ASP) drug fee limit for a procedure/date, times billed units.
  4. custom SQL — A Medicare DME fee (state fixed to GA) times units, marked up 4%.
Adjustments — all apply, in order
  1. multiple-endoscopy reduction (contract rules)
  2. multiple-procedure reduction (contract rules) — base codes 2; pays 100/50%
  3. custom SQL — For charges flagged with a custom 'ML' (manual-limit) code = 'Yes', applies a flat 15% reduction (Allowed*0.85) unless the charge carries modifier TC/AS or its code falls in one of several excluded ranges/patterns (alpha-prefixed codes, 95xxx, lab 80047-89398, radiology 70010-79999, immunization 90281-90470/90475-90749, cardio 93000-93278).
  4. modifier 50 present → 150% of the running amount
  5. modifier 22 present → 135% of the running amount
  6. modifier 52 present → 90% of the running amount
  7. modifier 62 present → 62.5% of the running amount
  8. modifier 80 present → 16% of the running amount
  9. modifier 81 present → 16% of the running amount
  10. modifier 82 present → 16% of the running amount
  11. modifier AS present → 13.6% of the running amount
  12. modifier 78 present → 69% of the running amount
  13. cap each charge and the account total at 100% of billed charges
Medicare-Profee-Humana4 base · 13 adj
Humana EHN Medicare
Profee · all facilities · 2020-07-01 → 2099-12-31
Base terms — first match wins
  1. 100% of the Non-Covered fee schedule
  2. custom SQL — Medicare RVU-based fee via a CommonData table-valued function: resolves the facility's ZIP and facility/clinic type, requests the 'second' RVU value in the function's date-relative sequence (Transitioned value type, OPPS-enabled), and multiplies that fee by Units and a flat 2% markup.
  3. custom SQL — The national Medicare ASP drug fee limit for a procedure code, times units, marked up 2%.
  4. custom SQL — 102% of the Georgia state Medicare DME fee for a procedure/modifier/date, times billed units.
Adjustments — all apply, in order
  1. multiple-endoscopy reduction (contract rules)
  2. multiple-procedure reduction (contract rules) — base codes 2; pays 100/50%
  3. custom SQL — For charges flagged with a custom 'ML' (manual-limit) code = 'Yes', applies a flat 15% reduction (Allowed*0.85) unless the charge carries modifier TC/AS or its code falls in one of several excluded ranges/patterns (alpha-prefixed codes, 95xxx, lab 80047-89398, radiology 70010-79999, immunization 90281-90470/90475-90749, cardio 93000-93278).
  4. modifier 50 present → 150% of the running amount
  5. modifier 22 present → 135% of the running amount
  6. modifier 52 present → 90% of the running amount
  7. modifier 62 present → 62.5% of the running amount
  8. modifier 80 present → 16% of the running amount
  9. modifier 81 present → 16% of the running amount
  10. modifier 82 present → 16% of the running amount
  11. modifier AS present → 13.6% of the running amount
  12. modifier 78 present → 69% of the running amount
  13. cap each charge and the account total at 100% of billed charges
UHC-Medicare-GAR-Facility5 base · 4 adj
UHC Medicare
Facility · 2-GAR002, 1-GAR002 · 2022-01-01 → 2999-12-31
Base terms — first match wins
  1. 100% of the Non-Covered fee schedule
  2. 100% of Medicare RVU
  3. 100% of Medicare lab
  4. 100% of Medicare drug
  5. 100% of Medicare DME
Adjustments — all apply, in order
  1. modifier 50 present → 150% of the running amount
  2. multiple-procedure reduction (contract rules) — base codes 2; pays 100/50%
  3. rescale by a percentage read from the Mid-Level-Charges schedule — when IsMidLevel Yes is present
  4. cap each charge and the account total at 100% of billed charges
UHC-Medicare-GAR-Profee5 base · 4 adj
UHC Medicare
Profee · 2-GAR002 · 2022-01-01 → 2999-12-31
Base terms — first match wins
  1. 100% of the Non-Covered fee schedule
  2. 100% of Medicare RVU
  3. 100% of Medicare lab
  4. 100% of Medicare drug
  5. 100% of Medicare DME
Adjustments — all apply, in order
  1. modifier 50 present → 150% of the running amount
  2. multiple-procedure reduction (contract rules) — base codes 2; pays 100/50%
  3. rescale by a percentage read from the Mid-Level-Charges schedule — when IsMidLevel Yes is present
  4. cap each charge and the account total at 100% of billed charges
United Healthcare MWEC Profee14 base · 19 adj
United Healthcare
Profee · 4-MID005, 3-MID005, 2-MID005 · 2024-01-01 → 2024-10-31
Base terms — first match wins
  1. 100% of the MWEC-UHC-Carveouts fee schedule
  2. computed expression (operands follow)
  3. 100% of the MWEC-UHC-Medicare-Multiplier fee schedule
  4. Multiply 100% of Medicare drug
  5. computed expression (operands follow)
  6. 100% of the MWEC-UHC-Medicare-Multiplier fee schedule
  7. Multiply 100% of Medicare DME (OH, rates as of 2020-01-01)
  8. computed expression (operands follow)
  9. 100% of the MWEC-UHC-Medicare-Multiplier fee schedule
  10. Multiply 100% of Medicare lab (OH, rates as of 2020-01-01)
  11. computed expression (operands follow)
  12. 100% of the MWEC-UHC-Medicare-Multiplier fee schedule
  13. Multiply 100% of Medicare RVU (rates as of 2020-01-01)
  14. 20% of billed charges
Adjustments — all apply, in order
  1. Medicare multiple-procedure reduction — base codes 2; pays 100/50%
  2. Medicare multiple-endoscopy reduction
  3. Medicare multiple-radiology reduction
  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 54 present → 80% of the running amount
  9. modifier 55 present → 20% of the running amount
  10. modifier 62 present → 62.5% of the running amount
  11. modifier 78 present → 70% of the running amount
  12. modifier 80 present → 16% of the running amount
  13. modifier 81 present → 16% of the running amount
  14. modifier 82 present → 16% of the running amount
  15. modifier AS present → 14% of the running amount
  16. modifier QY present → 50% of the running amount
  17. modifier QK present → 50% of the running amount
  18. modifier QX present → 50% of the running amount
  19. cap each charge and the account total at 100% of billed charges
United Healthcare MWEC Profee14 base · 19 adj
United Healthcare
Profee · 4-MID005, 3-MID005, 2-MID005 · 2024-11-01 → 2099-01-01
Base terms — first match wins
  1. 100% of the MWEC-UHC-Carveouts fee schedule
  2. computed expression (operands follow)
  3. 100% of the MWEC-UHC-Medicare-Multiplier fee schedule
  4. Multiply 100% of Medicare drug
  5. computed expression (operands follow)
  6. 100% of the MWEC-UHC-Medicare-Multiplier fee schedule
  7. Multiply 100% of Medicare DME (rates as of 2020-01-01)
  8. computed expression (operands follow)
  9. 100% of the MWEC-UHC-Medicare-Multiplier fee schedule
  10. Multiply 100% of Medicare lab (rates as of 2020-01-01)
  11. computed expression (operands follow)
  12. 100% of the MWEC-UHC-Medicare-Multiplier fee schedule
  13. Multiply 100% of Medicare RVU (rates as of 2020-01-01)
  14. 20% of billed charges
Adjustments — all apply, in order
  1. Medicare multiple-procedure reduction — base codes 2; pays 100/50%
  2. Medicare multiple-endoscopy reduction
  3. Medicare multiple-radiology reduction
  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 54 present → 80% of the running amount
  9. modifier 55 present → 20% of the running amount
  10. modifier 62 present → 62.5% of the running amount
  11. modifier 78 present → 70% of the running amount
  12. modifier 80 present → 16% of the running amount
  13. modifier 81 present → 16% of the running amount
  14. modifier 82 present → 16% of the running amount
  15. modifier AS present → 14% of the running amount
  16. modifier QY present → 50% of the running amount
  17. modifier QK present → 50% of the running amount
  18. modifier QX present → 50% of the running amount
  19. cap each charge and the account total at 100% of billed charges
UnitedHealthcare-EHN3 base · 1 adj
United Healthcare PPO
Profee · all facilities · 2020-07-01 → 2099-12-31
Base terms — first match wins
  1. 100% of the Non-Covered fee schedule
  2. custom SQL — Emory Healthcare Network's negotiated UHC fee-schedule rate per unit for a procedure, keyed by insurance, 26/TC modifier, provider type (OD vs MD derived from taxonomy), facility clinic/non-clinic flag, and a UHC contract region resolved from the facility.
  3. custom SQL — UHC (Emory) percent-of-charges: multiplies the charge's own billed amount directly by a percentage looked up from a customer POC table, keyed by insurance, TC/26 modifier, procedure code, provider type (Optometrist vs other), facility type, and UHC region.
Adjustments — all apply, in order
  1. multiple-procedure reduction (contract rules) — base codes 2, 3; pays 100/50%
UnitedHealthcare-GAR-Profee3 base · 4 adj
United Healthcare
Profee · 2-GAR002, 1-GAR002 · 2022-01-01 → 2999-12-31
Base terms — first match wins
  1. 100% of the Non-Covered fee schedule
  2. 100% of the Profee-Fees fee schedule
  3. percent-of-charges, rate read from the Profee-PoC schedule
Adjustments — all apply, in order
  1. multiple-procedure reduction (contract rules) — base codes 2; pays 100/50%
  2. custom SQL — For charges flagged with a custom 'ML' (manual-limit) code = 'Yes', applies a flat 15% reduction (Allowed*0.85) unless the charge carries modifier TC/AS or its code falls in one of several excluded ranges/patterns (alpha-prefixed codes, 95xxx, lab 80047-89398, radiology 70010-79999, immunization 90281-90470/90475-90749, cardio 93000-93278).
  3. modifier 50 present → 150% of the running amount
  4. cap each charge and the account total at 100% of billed charges
UnitedHealthcare-GEP-Profee3 base · 4 adj
United Healthcare
Profee · 12 named facilities · 2022-01-01 → 2999-12-31
Base terms — first match wins
  1. 100% of the Non-Covered fee schedule
  2. 100% of the Profee-Fees fee schedule
  3. percent-of-charges, rate read from the Profee-PoC schedule
Adjustments — all apply, in order
  1. multiple-procedure reduction (contract rules) — base codes 2; pays 100/50%
  2. custom SQL — For charges flagged with a custom 'ML' (manual-limit) code = 'Yes', applies a flat 15% reduction (Allowed*0.85) unless the charge carries modifier TC/AS or its code falls in one of several excluded ranges/patterns (alpha-prefixed codes, 95xxx, lab 80047-89398, radiology 70010-79999, immunization 90281-90470/90475-90749, cardio 93000-93278).
  3. modifier 50 present → 150% of the running amount
  4. cap each charge and the account total at 100% of billed charges
UnitedHealthcare-MWEC-Facility2 base · 13 adj
United Healthcare
Facility · 4-MID005, 3-MID005, 2-MID005 · 2024-01-01 → 2999-12-31
Base terms — first match wins
  1. 100% of the MWEC-UHC-ASC-Carveouts fee schedule
  2. 100% of the MWEC-UHC-Grouper-Rates fee schedule
Adjustments — all apply, in order
  1. multiple-endoscopy reduction (contract rules)
  2. modifier 50 present → 150% of the running amount
  3. multiple-procedure reduction (contract rules) — base codes 2; pays 100/50/25%
  4. rescale by a percentage read from the Mid-Level-Charges schedule — when IsMidLevel Yes is present
  5. modifier 22 present → 135% of the running amount
  6. modifier 52 present → 90% of the running amount
  7. modifier 62 present → 62.5% of the running amount
  8. modifier 80 present → 16% of the running amount
  9. modifier 81 present → 16% of the running amount
  10. modifier 82 present → 16% of the running amount
  11. modifier AS present → 13.6% of the running amount
  12. modifier 78 present → 69% of the running amount
  13. cap each charge and the account total at 100% of billed charges
UnitedHealthcare-Profee3 base · 4 adj
United Healthcare
Facility, Profee · 15 named facilities · 2023-01-01 → 2999-12-31
United Healthcare
Facility, Profee · 14 named facilities · 2022-07-01 → 2999-12-31
Base terms — first match wins
  1. 100% of the Non-Covered fee schedule
  2. 100% of the Profee-Fees-FeePricingRecord fee schedule
  3. percent-of-charges, rate read from the Profee-PoC-FeePricingRecord schedule
Adjustments — all apply, in order
  1. multiple-procedure reduction (contract rules) — base codes 2; pays 100/50%
  2. custom SQL — For charges flagged with a custom 'ML' (manual-limit) code = 'Yes', applies a flat 15% reduction (Allowed*0.85) unless the charge carries modifier TC/AS or its code falls in one of several excluded ranges/patterns (alpha-prefixed codes, 95xxx, lab 80047-89398, radiology 70010-79999, immunization 90281-90470/90475-90749, cardio 93000-93278).
  3. modifier 50 present → 150% of the running amount
  4. cap each charge and the account total at 100% of billed charges
Wellcare-GAR-Profee3 base · 4 adj
Wellcare
Profee · 2-GAR002, 1-GAR002 · 2022-01-01 → 2999-12-31
Base terms — first match wins
  1. 100% of the Non-Covered fee schedule
  2. 100% of the Profee-Fees fee schedule
  3. percent-of-charges, rate read from the Profee-PoC schedule
Adjustments — all apply, in order
  1. multiple-procedure reduction (contract rules) — base codes 2; pays 100/50%
  2. custom SQL — For charges flagged with a custom 'ML' (manual-limit) code = 'Yes', applies a flat 15% reduction (Allowed*0.85) unless the charge carries modifier TC/AS or its code falls in one of several excluded ranges/patterns (alpha-prefixed codes, 95xxx, lab 80047-89398, radiology 70010-79999, immunization 90281-90470/90475-90749, cardio 93000-93278).
  3. modifier 50 present → 150% of the running amount
  4. cap each charge and the account total at 100% of billed charges

Cannot fire (13)

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

BCBS-GA-Clayton-Profee-01-01-2022 · no contract map3 base · 4 adj
no contract map — cannot be resolved
Base terms — first match wins
  1. 100% of the Non-Covered fee schedule
  2. 100% of the Profee-Fees fee schedule
  3. percent-of-charges, rate read from the Profee-PoC schedule
Adjustments — all apply, in order
  1. multiple-procedure reduction (contract rules) — base codes 2; pays 100/50%
  2. custom SQL — For charges flagged with a custom 'ML' (manual-limit) code = 'Yes', applies a flat 15% reduction (Allowed*0.85) unless the charge carries modifier TC/AS or its code falls in one of several excluded ranges/patterns (alpha-prefixed codes, 95xxx, lab 80047-89398, radiology 70010-79999, immunization 90281-90470/90475-90749, cardio 93000-93278).
  3. modifier 50 present → 150% of the running amount
  4. cap each charge and the account total at 100% of billed charges
BCBS-GA-GEP-Profee-01-01-2022 · no contract map3 base · 4 adj
no contract map — cannot be resolved
Base terms — first match wins
  1. 100% of the Non-Covered fee schedule
  2. 100% of the Profee-Fees fee schedule
  3. 80% of billed charges
Adjustments — all apply, in order
  1. multiple-procedure reduction (contract rules) — base codes 2; pays 100/50%
  2. custom SQL — For charges flagged with a custom 'ML' (manual-limit) code = 'Yes', applies a flat 15% reduction (Allowed*0.85) unless the charge carries modifier TC/AS or its code falls in one of several excluded ranges/patterns (alpha-prefixed codes, 95xxx, lab 80047-89398, radiology 70010-79999, immunization 90281-90470/90475-90749, cardio 93000-93278).
  3. modifier 50 present → 150% of the running amount
  4. cap each charge and the account total at 100% of billed charges
Cigna · no contract map3 base · 1 adj
no contract map — cannot be resolved
Base terms — first match wins
  1. 100% of the Non-Covered fee schedule
  2. custom SQL — Prices an ophthalmology charge from a customer-specific per-unit fee schedule keyed by insurance, procedure code, whether the '26' (professional-component) modifier is present, place-of-service (facility vs non-facility), and whether the billing provider is classified OD or MD, times units.
  3. custom SQL — Percent-of-charges pricing for optometry/ophthalmology services keyed by facility type (in/out of hospital), modifier (26 vs not), procedure code, and the billing provider's type (Optometrist->OD vs Ophthalmology/other->MD): Amount = Charged * (Percent/100).
Adjustments — all apply, in order
  1. multiple-procedure reduction (contract rules) — base codes 2, 3; pays 100/50%
Humana · no contract map3 base · 1 adj
no contract map — cannot be resolved
Base terms — first match wins
  1. 100% of the Non-Covered fee schedule
  2. custom SQL — Prices an ophthalmology charge from a customer-specific per-unit fee schedule keyed by insurance, procedure code, whether the '26' (professional-component) modifier is present, place-of-service (facility vs non-facility), and whether the billing provider is classified OD or MD, times units.
  3. custom SQL — Percent-of-charges pricing for optometry/ophthalmology services keyed by facility type (in/out of hospital), modifier (26 vs not), procedure code, and the billing provider's type (Optometrist->OD vs Ophthalmology/other->MD): Amount = Charged * (Percent/100).
Adjustments — all apply, in order
  1. multiple-procedure reduction (contract rules) — base codes 2, 3; pays 100/50%
United Healthcare MWEC Profee 10% proposal · no contract map14 base · 19 adj
no contract map — cannot be resolved
Base terms — first match wins
  1. 110% of the MWEC-UHC-Carveouts fee schedule
  2. computed expression (operands follow)
  3. 110% of the MWEC-UHC-Medicare-Multiplier fee schedule
  4. Multiply 100% of Medicare drug
  5. computed expression (operands follow)
  6. 110% of the MWEC-UHC-Medicare-Multiplier fee schedule
  7. Multiply 100% of Medicare DME (rates as of 2020-01-01)
  8. computed expression (operands follow)
  9. 110% of the MWEC-UHC-Medicare-Multiplier fee schedule
  10. Multiply 100% of Medicare lab (rates as of 2020-01-01)
  11. computed expression (operands follow)
  12. 110% of the MWEC-UHC-Medicare-Multiplier fee schedule
  13. Multiply 100% of Medicare RVU (rates as of 2020-01-01)
  14. 30% of billed charges
Adjustments — all apply, in order
  1. Medicare multiple-procedure reduction — base codes 2; pays 100/50%
  2. Medicare multiple-endoscopy reduction
  3. Medicare multiple-radiology reduction
  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 54 present → 80% of the running amount
  9. modifier 55 present → 20% of the running amount
  10. modifier 62 present → 62.5% of the running amount
  11. modifier 78 present → 70% of the running amount
  12. modifier 80 present → 16% of the running amount
  13. modifier 81 present → 16% of the running amount
  14. modifier 82 present → 16% of the running amount
  15. modifier AS present → 14% of the running amount
  16. modifier QY present → 50% of the running amount
  17. modifier QK present → 50% of the running amount
  18. modifier QX present → 50% of the running amount
  19. cap each charge and the account total at 100% of billed charges
United Healthcare MWEC Profee 15% proposal · no contract map14 base · 19 adj
no contract map — cannot be resolved
Base terms — first match wins
  1. 115% of the MWEC-UHC-Carveouts fee schedule
  2. computed expression (operands follow)
  3. 115% of the MWEC-UHC-Medicare-Multiplier fee schedule
  4. Multiply 100% of Medicare drug
  5. computed expression (operands follow)
  6. 115% of the MWEC-UHC-Medicare-Multiplier fee schedule
  7. Multiply 100% of Medicare DME (rates as of 2020-01-01)
  8. computed expression (operands follow)
  9. 115% of the MWEC-UHC-Medicare-Multiplier fee schedule
  10. Multiply 100% of Medicare lab (rates as of 2020-01-01)
  11. computed expression (operands follow)
  12. 115% of the MWEC-UHC-Medicare-Multiplier fee schedule
  13. Multiply 100% of Medicare RVU (rates as of 2020-01-01)
  14. 35% of billed charges ⚠︎ named “30% Bill Charges Fallback” but configured at 35%
Adjustments — all apply, in order
  1. Medicare multiple-procedure reduction — base codes 2; pays 100/50%
  2. Medicare multiple-endoscopy reduction
  3. Medicare multiple-radiology reduction
  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 54 present → 80% of the running amount
  9. modifier 55 present → 20% of the running amount
  10. modifier 62 present → 62.5% of the running amount
  11. modifier 78 present → 70% of the running amount
  12. modifier 80 present → 16% of the running amount
  13. modifier 81 present → 16% of the running amount
  14. modifier 82 present → 16% of the running amount
  15. modifier AS present → 14% of the running amount
  16. modifier QY present → 50% of the running amount
  17. modifier QK present → 50% of the running amount
  18. modifier QX present → 50% of the running amount
  19. cap each charge and the account total at 100% of billed charges
United Healthcare MWEC Profee 5% proposal · no contract map14 base · 19 adj
no contract map — cannot be resolved
Base terms — first match wins
  1. 105% of the MWEC-UHC-Carveouts fee schedule
  2. computed expression (operands follow)
  3. 105% of the MWEC-UHC-Medicare-Multiplier fee schedule
  4. Multiply 100% of Medicare drug
  5. computed expression (operands follow)
  6. 105% of the MWEC-UHC-Medicare-Multiplier fee schedule
  7. Multiply 100% of Medicare DME (rates as of 2020-01-01)
  8. computed expression (operands follow)
  9. 105% of the MWEC-UHC-Medicare-Multiplier fee schedule
  10. Multiply 100% of Medicare lab (rates as of 2020-01-01)
  11. computed expression (operands follow)
  12. 105% of the MWEC-UHC-Medicare-Multiplier fee schedule
  13. Multiply 100% of Medicare RVU (rates as of 2020-01-01)
  14. 25% of billed charges
Adjustments — all apply, in order
  1. Medicare multiple-procedure reduction — base codes 2; pays 100/50%
  2. Medicare multiple-endoscopy reduction
  3. Medicare multiple-radiology reduction
  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 54 present → 80% of the running amount
  9. modifier 55 present → 20% of the running amount
  10. modifier 62 present → 62.5% of the running amount
  11. modifier 78 present → 70% of the running amount
  12. modifier 80 present → 16% of the running amount
  13. modifier 81 present → 16% of the running amount
  14. modifier 82 present → 16% of the running amount
  15. modifier AS present → 14% of the running amount
  16. modifier QY present → 50% of the running amount
  17. modifier QK present → 50% of the running amount
  18. modifier QX present → 50% of the running amount
  19. cap each charge and the account total at 100% of billed charges
UnitedHealthcare · no contract map3 base · 1 adj
no contract map — cannot be resolved
Base terms — first match wins
  1. 100% of the Non-Covered fee schedule
  2. custom SQL — Prices an ophthalmology charge from a customer-specific per-unit fee schedule keyed by insurance, procedure code, whether the '26' (professional-component) modifier is present, place-of-service (facility vs non-facility), and whether the billing provider is classified OD or MD, times units.
  3. custom SQL — Percent-of-charges pricing for optometry/ophthalmology services keyed by facility type (in/out of hospital), modifier (26 vs not), procedure code, and the billing provider's type (Optometrist->OD vs Ophthalmology/other->MD): Amount = Charged * (Percent/100).
Adjustments — all apply, in order
  1. multiple-procedure reduction (contract rules) — base codes 2, 3; pays 100/50%
UnitedHealthcare-GEA-Profee · no contract map3 base · 4 adj
no contract map — cannot be resolved
Base terms — first match wins
  1. 100% of the Non-Covered fee schedule
  2. 100% of the Profee-Fees fee schedule
  3. 60% of billed charges
Adjustments — all apply, in order
  1. multiple-procedure reduction (contract rules) — base codes 2; pays 100/50%
  2. custom SQL — For charges flagged with a custom 'ML' (manual-limit) code = 'Yes', applies a flat 15% reduction (Allowed*0.85) unless the charge carries modifier TC/AS or its code falls in one of several excluded ranges/patterns (alpha-prefixed codes, 95xxx, lab 80047-89398, radiology 70010-79999, immunization 90281-90470/90475-90749, cardio 93000-93278).
  3. modifier 50 present → 150% of the running amount
  4. cap each charge and the account total at 100% of billed charges
UnitedHealthcare-MWEC-Facility-Proposal · no contract map2 base · 13 adj
no contract map — cannot be resolved
Base terms — first match wins
  1. 100% of the MWEC-UHC-ASC-Carveouts fee schedule
  2. 100% of the MWEC-UHC-Grouper-Rates-Proposal fee schedule
Adjustments — all apply, in order
  1. multiple-endoscopy reduction (contract rules)
  2. modifier 50 present → 150% of the running amount
  3. multiple-procedure reduction (contract rules) — base codes 2; pays 100/50/25%
  4. rescale by a percentage read from the Mid-Level-Charges schedule — when IsMidLevel Yes is present
  5. modifier 22 present → 135% of the running amount
  6. modifier 52 present → 90% of the running amount
  7. modifier 62 present → 62.5% of the running amount
  8. modifier 80 present → 16% of the running amount
  9. modifier 81 present → 16% of the running amount
  10. modifier 82 present → 16% of the running amount
  11. modifier AS present → 13.6% of the running amount
  12. modifier 78 present → 69% of the running amount
  13. cap each charge and the account total at 100% of billed charges
UnitedHealthcare-Piedmont · no contract map3 base · 1 adj
no contract map — cannot be resolved
Base terms — first match wins
  1. 100% of the Non-Covered fee schedule
  2. 100% of the Fixed-Fees fee schedule
  3. 55.74% of billed charges
Adjustments — all apply, in order
  1. multiple-procedure reduction (contract rules) — base codes 2, 3; pays 100/50%
Wellcare · no contract map3 base · 1 adj
no contract map — cannot be resolved
Base terms — first match wins
  1. 100% of the Non-Covered fee schedule
  2. custom SQL — Prices an ophthalmology charge from a customer-specific per-unit fee schedule keyed by insurance, procedure code, whether the '26' (professional-component) modifier is present, place-of-service (facility vs non-facility), and whether the billing provider is classified OD or MD, times units.
  3. custom SQL — Percent-of-charges pricing for optometry/ophthalmology services keyed by facility type (in/out of hospital), modifier (26 vs not), procedure code, and the billing provider's type (Optometrist->OD vs Ophthalmology/other->MD): Amount = Charged * (Percent/100).
Adjustments — all apply, in order
  1. multiple-procedure reduction (contract rules) — base codes 2, 3; pays 100/50%
Wellcare-Medicare-GAR-Profee · no contract map3 base · 4 adj
no contract map — cannot be resolved
Base terms — first match wins
  1. 100% of the Non-Covered fee schedule
  2. 100% of the Profee-Fees fee schedule
  3. 70% of billed charges
Adjustments — all apply, in order
  1. multiple-procedure reduction (contract rules) — base codes 2; pays 100/50%
  2. custom SQL — For charges flagged with a custom 'ML' (manual-limit) code = 'Yes', applies a flat 15% reduction (Allowed*0.85) unless the charge carries modifier TC/AS or its code falls in one of several excluded ranges/patterns (alpha-prefixed codes, 95xxx, lab 80047-89398, radiology 70010-79999, immunization 90281-90470/90475-90749, cardio 93000-93278).
  3. modifier 50 present → 150% of the running amount
  4. cap each charge and the account total at 100% of billed charges