Customer detail

Femwell

34
live contracts
9
cannot fire
15
calc types
123
SQL bodies
119
of those blocked
0
map conflicts

Methodology mix

SqlExpression200
PercentOfFees138
FlatPercentOfCharges114
ModifierAdjustment86
MultipleProcedureAdjustment65
LesserOfAdjustment20
ChargeLevelSqlAdjustment16
MultipleEndoscopyAdjustment7
CaseRate6
PercentageAdjustment5
MedicareRVU4
MedicareDrug2
MedicareLab2
MedicareDME2
ExcludedChargeAdjustment1

Contracts

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

Aetna Medicare7 base · 13 adj
Aetna Medicare
Profee · all facilities · 2009-01-01 → 2020-11-30
Base terms — first match wins
  1. custom SQL — Flat $150 fee for preventive-medicine E/M codes 99384-99397.
  2. 100% of the Medicare-Drug fee schedule
  3. 100% of the Medicare-Lab fee schedule
  4. 100% of the Medicare-DME fee schedule
  5. 100% of the Medicare-RVU-Hospital/ASC fee schedule — when POS 11 is absent
  6. 100% of the Medicare-RVU-Clinic fee schedule — when POS 11 is present
  7. 100% of billed charges
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
Aetna Medicare-20207 base · 13 adj
Aetna Medicare
Profee · all facilities · 2020-12-01 → 2999-12-31
Base terms — first match wins
  1. custom SQL — Aetna market fee-schedule amount for a procedure: either a fixed negotiated fee, or (if not fixed) a compensation-category-specific multiplier times an Aetna 'FL04' geo-area base market rate, distinguishing facility vs. non-facility place of service.
  2. 100% of the Medicare-Drug fee schedule
  3. 100% of the Medicare-Lab fee schedule
  4. 100% of the Medicare-DME fee schedule
  5. 100% of the Medicare-RVU-Hospital/ASC fee schedule — when POS 11 is absent
  6. 100% of the Medicare-RVU-Clinic fee schedule — when POS 11 is present
  7. custom SQL — Aetna market fee-schedule rate for a fixed FL04 geographic area (hardcoded), for the billing/supervising provider's compensation category, scaled by an AMFS Medicare-rate multiplier tied to that same compensation category.
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 — Reduces the already-computed allowed amount to 85% of itself for charges that are not TC/AS-modified and whose procedure code falls outside a hardcoded set of lab, radiology, immunization, cardiology-diagnostic, and alphanumeric-prefixed code ranges — a blanket markdown for 'everything except these carve-outs'. — when IsMidLevel Yes is present
  4. modifier 50 present → 150% of the running amount — when AetnaCompensationCategory 1 is present
  5. modifier 50 present → 150% of the running amount
  6. modifier 22 present → 135% of the running amount
  7. modifier 52 present → 90% of the running amount
  8. modifier 62 present → 62.5% of the running amount
  9. modifier 80 present → 16% of the running amount
  10. modifier 81 present → 16% of the running amount
  11. modifier 82 present → 16% of the running amount
  12. modifier AS present → 13.6% of the running amount
  13. modifier 78 present → 69% of the running amount
Aetna-V218 base · 3 adj
Aetna
Profee · all facilities · 2017-11-15 → 2099-12-31
Base terms — first match wins
  1. custom SQL — Aetna market fee-schedule amount for a procedure (near-duplicate of sibling snippet dd8a6aa021cd37bc for a different Aetna contract table set): either a fixed negotiated fee, or a compensation-category multiplier times an Aetna 'FL04' geo-area base rate, with an added office-only carveout rule that forces the non-facility rate regardless of actual place of service for certain services.
  2. custom SQL — Aetna DME rate: the Medicare DME fee for a facility-specific DME schedule variant, scaled by a compensation-category- and Medicare-flag-specific multiplier negotiated under this contract.
  3. custom SQL — Aetna clinical-lab fee: a CommonData Medicare lab-fee-schedule amount (resolved via an Aetna facility-to-schedule crosswalk) scaled by an Aetna compensation-category rate multiplier tied to the provider.
  4. custom SQL — Aetna-specific RVU-based fee: a Medicare RVU amount (via a customer-curated Aetna RVU schedule map into CommonData's Medicare RVU table) multiplied by a compensation-category-specific 'Medicare-based' rate multiplier keyed off the billing provider.
  5. custom SQL — Prices an Aetna AMFS (Aetna Market Fee Schedule) charge as (base rate for procedure+locality+facility-type, with a fallback to the blank-modifier row when the exact modifier isn't scheduled) times a compensation-category multiplier, both resolved through layered Aetna-specific crosswalks; locality derived from a facility-locality crosswalk mapped to a 3-way hardcoded GeoArea.
  6. 60% of billed charges — when AetnaCompensationCategory 15 is present
  7. 60% of billed charges — when AetnaCompensationCategory 13 is present
  8. 60% of billed charges — when AetnaCompensationCategory 12 is present
  9. 60% of billed charges — when AetnaCompensationCategory 11 is present
  10. 60% of billed charges — when AetnaCompensationCategory 10 is present
  11. 60% of billed charges — when AetnaCompensationCategory 9 is present
  12. 60% of billed charges — when AetnaCompensationCategory 8 is present
  13. 60% of billed charges — when AetnaCompensationCategory 7 is present
  14. 60% of billed charges — when AetnaCompensationCategory 6 is present
  15. 60% of billed charges — when AetnaCompensationCategory 4 is present
  16. 60% of billed charges — when AetnaCompensationCategory 3 is present
  17. 60% of billed charges — when AetnaCompensationCategory 2 is present
  18. 60% of billed charges — when AetnaCompensationCategory 1 is present
Adjustments — all apply, in order
  1. multiple-procedure reduction (contract rules) — base codes 2, 3; pays 100/60%
  2. modifier 80 present → 16% of the running amount
  3. rescale by a percentage read from the Mid-Level-Charges schedule — when IsMidLevel Yes is present
AvMed28 base · 4 adj
AvMed
Profee · all facilities · 2019-05-01 → 2020-04-30
Base terms — first match wins
  1. 100% of the Telemedicine fee schedule — when AvMedSpecialtyCategory 15 is present
  2. 100% of the Per-Diem fee schedule — when AvMedSpecialtyCategory 11 is present
  3. custom SQL — A flat carve-out dollar amount for AvMed-insured claims, keyed by the pricing provider's specialty, a customer-specific locality bucket (Ft. Lauderdale folded into the Miami/South bucket), a facility-vs-clinic flag, procedure code, and modifier.
  4. 100% of the AWP fee schedule
  5. 100% of the ASP fee schedule
  6. custom SQL — AvMed carveout rate: resolves provider specialty (AvmedSpecialtyMap) and facility locality/type (SourceFacilityLocalityMap, with a hardcoded Ft. Lauderdale-to-South-locality override), looks up a specialty/locality-specific schedule-type + rate year + multiplier from AvmedCarveoutSchedule, then multiplies that against the matching Medicare-based FeeScheduleRecord amount for the code.
  7. custom SQL — AvMed VitalMD (pre-May-2018 physician group) pricing: resolves provider specialty and facility locality, looks up the specialty's VitalMD schedule year and multiplier from TransformAvmedProvidersVitalMD, then multiplies by the corresponding Medicare-RVU FeeScheduleRecord amount.
  8. custom SQL — AvMed base specialty pricing (contracted-status variant): resolves specialty/contracted flag and facility locality, looks up a specialty/locality/facility-type/contracted multiplier from AvMedSpecialtyBaseSchedule, then multiplies by the Medicare-RVU FeeScheduleRecord amount for that place of service — no DME/Drug/Lab fallback, unlike near-identical siblings.
  9. custom SQL — AvMed Medicare 'fallback' pricing: resolves provider specialty and facility locality/type, looks up a fallback multiplier from AvmedMedicareFallback keyed by specialty/locality/facility-type, then multiplies by the Medicare-RVU FeeScheduleRecord amount for that place of service.
  10. 70% of billed charges — when AvMedSpecialtyCategory 20 is present
  11. 70% of billed charges — when AvMedSpecialtyCategory 19 is present
  12. 70% of billed charges — when AvMedSpecialtyCategory 18 is present
  13. 70% of billed charges — when AvMedSpecialtyCategory 16 is present
  14. 70% of billed charges — when AvMedSpecialtyCategory 15 is present
  15. 70% of billed charges — when AvMedSpecialtyCategory 14 is present
  16. 70% of billed charges — when AvMedSpecialtyCategory 13 is present
  17. 70% of billed charges — when AvMedSpecialtyCategory 12 is present
  18. 70% of billed charges — when AvMedSpecialtyCategory 11 is present
  19. 70% of billed charges — when AvMedSpecialtyCategory 10 is present
  20. 70% of billed charges — when AvMedSpecialtyCategory 9 is present
  21. 70% of billed charges — when AvMedSpecialtyCategory 8 is present
  22. 70% of billed charges — when AvMedSpecialtyCategory 7 is present
  23. 70% of billed charges — when AvMedSpecialtyCategory 6 is present
  24. 70% of billed charges — when AvMedSpecialtyCategory 5 is present
  25. 70% of billed charges — when AvMedSpecialtyCategory 4 is present
  26. 70% of billed charges — when AvMedSpecialtyCategory 3 is present
  27. 70% of billed charges — when AvMedSpecialtyCategory 2 is present
  28. 70% of billed charges — when AvMedSpecialtyCategory 1 is present
Adjustments — all apply, in order
  1. rescale by a percentage read from the Avmed-Mid-Level-Charges schedule — when IsMidLevel Yes is present
  2. multiple-procedure reduction (contract rules) — base codes 2; pays 100/0%
  3. custom SQL — Zeroes the allowed amount for any charge whose procedure code is classified as an 'OB Visit' in an AvMed CPT service-type rollup list.
  4. cap each charge and the account total at 100% of billed charges
AvMed-202029 base · 3 adj
AvMed
Profee · all facilities · 2020-05-01 → 2999-12-31
Base terms — first match wins
  1. 100% of the Telemedicine fee schedule — when AvMedSpecialtyCategory 15 is present
  2. 100% of the Per-Diem fee schedule — when AvMedSpecialtyCategory 11 is present
  3. custom SQL — AvMed fixed carveout fee: resolves provider specialty (AvmedSpecialtyMap) and facility locality/type (SourceFacilityLocalityMap, same Ft. Lauderdale hack), and returns a flat dollar amount from AvmedCarveoutFixed keyed exactly by specialty/locality/facility-type/procedure/modifier/date -- no Medicare base fee involved.
  4. custom SQL — AvMed AWP fee-schedule amount for a facility, multiplied by a specialty- and locality-specific negotiated multiplier (with Ft. Lauderdale grouped into the Miami/South locality bucket).
  5. custom SQL — AvMed drug/injectable ASP pricing: resolves provider specialty and locality, looks up an AvMed-specific ASP multiplier from TransformAvmedRate (filtered to drug/immunization/injection service descriptions), and multiplies by the AvMed ASP FeeScheduleRecord amount for the procedure.
  6. custom SQL — AvMed carveout rate (same shape as 164) with an added fallback: if the specialty/locality-specific schedule-type amount is missing and the schedule type isn't already RVU, it retries the lookup against the plain Medicare-RVU schedule.
  7. custom SQL — An AvMed 'VitalMD' fee: the Medicare RVU-based fee-schedule amount for the facility's (locality-adjusted, with a hardcoded Fort-Lauderdale-to-Miami locality grouping and a hardcoded facility-ID override for locality 3) place of service, times a provider-and-locality-specific VitalMD contract multiplier.
  8. custom SQL — AvMed base (non-VitalMD) specialty pricing: resolves specialty/contracted status for providers explicitly excluded from the VitalMD program, resolves facility locality, looks up a specialty/locality/facility-type/contracted-status multiplier from AvMedSpecialtyBaseSchedule, then multiplies by whichever of RVU/DME/Drug/Lab Medicare-based FeeScheduleRecord amounts matches (same COALESCE fallback chain as snippet 0f31d9fd11587e5b).
  9. custom SQL — AvMed Medicare-fallback rate: resolves specialty (AvmedSpecialtyMap) and facility locality/type (SourceFacilityLocalityMap, same Ft. Lauderdale hack), looks up a specialty/locality/facility-type multiplier from AvmedMedicareFallback, then multiplies it by whichever of the Medicare RVU/DME/Drug/Lab FeeScheduleRecord amounts is non-null for the code (checked in that priority order).
  10. 40% of billed charges — when AvMedSpecialtyCategory 21 is present
  11. 40% of billed charges — when AvMedSpecialtyCategory 20 is present
  12. 40% of billed charges — when AvMedSpecialtyCategory 19 is present
  13. 40% of billed charges — when AvMedSpecialtyCategory 18 is present
  14. 40% of billed charges — when AvMedSpecialtyCategory 16 is present
  15. 40% of billed charges — when AvMedSpecialtyCategory 15 is present
  16. 40% of billed charges — when AvMedSpecialtyCategory 14 is present
  17. 40% of billed charges — when AvMedSpecialtyCategory 13 is present
  18. 40% of billed charges — when AvMedSpecialtyCategory 12 is present
  19. 40% of billed charges — when AvMedSpecialtyCategory 11 is present
  20. 40% of billed charges — when AvMedSpecialtyCategory 10 is present
  21. 40% of billed charges — when AvMedSpecialtyCategory 9 is present
  22. 40% of billed charges — when AvMedSpecialtyCategory 8 is present
  23. 40% of billed charges — when AvMedSpecialtyCategory 7 is present
  24. 40% of billed charges — when AvMedSpecialtyCategory 6 is present
  25. 40% of billed charges — when AvMedSpecialtyCategory 5 is present
  26. 40% of billed charges — when AvMedSpecialtyCategory 4 is present
  27. 40% of billed charges — when AvMedSpecialtyCategory 3 is present
  28. 40% of billed charges — when AvMedSpecialtyCategory 2 is present
  29. 40% of billed charges — when AvMedSpecialtyCategory 1 is present
Adjustments — all apply, in order
  1. rescale by a percentage read from the Avmed-Mid-Level-Charges schedule — when IsMidLevel Yes is present
  2. multiple-procedure reduction (contract rules) — base codes 2; pays 100/0%
  3. custom SQL — Zeroes the allowed amount for any charge whose procedure code is classified as an 'OB Visit' in an AvMed CPT service-type rollup list.
AvMed-Medicare24 base · 2 adj
AvMed Medicare
Profee · all facilities · 2019-01-01 → 2999-12-31
Base terms — first match wins
  1. 100% of the Per-Diem fee schedule — when AvMedSpecialtyCategory 11 is present
  2. custom SQL — The Medicare-variant of the AvMed carve-out: a flat dollar amount keyed by specialty, facility-vs-clinic flag, procedure code, and modifier (no locality dimension, unlike the sibling snippet).
  3. custom SQL — Prices an AvMed Medicare carve-out procedure: resolves provider specialty (AvmedSpecialtyMap) and facility type/locality (SourceFacilityLocalityMap), looks up a per-specialty carve-out schedule type and multiplier from AvmedMedicareCarveoutSchedule, then fetches the matching FeeScheduleRecord amount for that schedule/date and multiplies by the carve-out multiplier.
  4. custom SQL — Prices an AvMed Medicare-referenced professional service: resolves the provider's contracted specialty (AvmedSpecialtyMap) and facility locality/type (SourceFacilityLocalityMap), then multiplies whichever of RVU/DME/Drug/Lab Medicare fee-schedule amounts matches the procedure by an AvMed-specific specialty/facility-type multiplier from AvMedMedicareSpecialtyBaseSchedule.
  5. 100% of the Fixed-Fees fee schedule — when AvMedSpecialtyCategory 21 is present
  6. 100% of the Fixed-Fees fee schedule — when AvMedSpecialtyCategory 20 is present
  7. 100% of the Fixed-Fees fee schedule — when AvMedSpecialtyCategory 19 is present
  8. 100% of the Fixed-Fees fee schedule — when AvMedSpecialtyCategory 18 is present
  9. 100% of the Fixed-Fees fee schedule — when AvMedSpecialtyCategory 16 is present
  10. 100% of the Fixed-Fees fee schedule — when AvMedSpecialtyCategory 15 is present
  11. 100% of the Fixed-Fees fee schedule — when AvMedSpecialtyCategory 14 is present
  12. 100% of the Fixed-Fees fee schedule — when AvMedSpecialtyCategory 13 is present
  13. 100% of the Fixed-Fees fee schedule — when AvMedSpecialtyCategory 12 is present
  14. 100% of the Fixed-Fees fee schedule — when AvMedSpecialtyCategory 11 is present
  15. 80% of billed charges — when AvMedSpecialtyCategory 10 is present
  16. 80% of billed charges — when AvMedSpecialtyCategory 9 is present
  17. 100% of the Fixed-Fees fee schedule — when AvMedSpecialtyCategory 8 is present
  18. 80% of billed charges — when AvMedSpecialtyCategory 7 is present
  19. 100% of the Fixed-Fees fee schedule — when AvMedSpecialtyCategory 6 is present
  20. 100% of the Fixed-Fees fee schedule — when AvMedSpecialtyCategory 5 is present
  21. 100% of the Fixed-Fees fee schedule — when AvMedSpecialtyCategory 4 is present
  22. 100% of the Fixed-Fees fee schedule — when AvMedSpecialtyCategory 3 is present
  23. 100% of the Fixed-Fees fee schedule — when AvMedSpecialtyCategory 2 is present
  24. 100% of the Fixed-Fees fee schedule — when AvMedSpecialtyCategory 1 is present
Adjustments — all apply, in order
  1. rescale by a percentage read from the Avmed-Mid-Level-Charges schedule — when IsMidLevel Yes is present
  2. cap each charge and the account total at 100% of billed charges
BCBS FL Medicare8 base · 13 adj
BCBS FL Medicare
Profee · all facilities · 2017-01-01 → 2099-12-31
Base terms — first match wins
  1. 100% of the Medicare-Drug fee schedule
  2. 100% of the Medicare-Lab fee schedule
  3. 100% of the Medicare-DME fee schedule
  4. 100% of the Medicare-RVU-Hospital/ASC-Secondary fee schedule — when POS 11 is absent; Exhibit B Supervising Provider Yes is present
  5. 100% of the Medicare-RVU-Hospital/ASC fee schedule — when POS 11 is absent
  6. 100% of the Medicare-RVU-Clinic-Secondary fee schedule — when POS 11 is present; Exhibit B Supervising Provider Yes is present
  7. 100% of the Medicare-RVU-Clinic fee schedule — when POS 11 is present
  8. 100% of billed charges
Adjustments — all apply, in order
  1. multiple-endoscopy reduction (contract rules)
  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. 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
BCBS-FL-Profee-V223 base · 14 adj
BCBS FL
Profee · all facilities · 2017-01-01 → 9999-12-31
Base terms — first match wins
  1. case rate from All-Inclusive-Specialty-OBGYN (Charge-level codes) — when BCBSSpecialtyCategory 12 is present
  2. case rate from All-Inclusive-Specialty-OBGYN (Charge-level codes) — when BCBSSpecialtyCategory 7 is present
  3. case rate from All-Inclusive-Specialty-MFM-GYN (Charge-level codes) — when BCBSSpecialtyCategory 11 is present
  4. case rate from All-Inclusive-Specialty-MFM-GYN (Charge-level codes) — when BCBSSpecialtyCategory 4 is present
  5. case rate from All-Inclusive-Specialty-MFM-GYN (Charge-level codes) — when BCBSSpecialtyCategory 10 is present
  6. case rate from All-Inclusive-Specialty-MFM-GYN (Charge-level codes) — when BCBSSpecialtyCategory 3 is present
  7. custom SQL — BCBS Florida carveout: resolves provider specialty via a BCBS provider crosswalk and facility type, then looks up a flat carveout dollar amount from TransformBCBSFLCarveout keyed by CPT/specialty/place-of-service/effective date, excluding rows flagged Type='Additional'.
  8. custom SQL — BCBS lab fee for a code, priced per the rendering provider's BCBS specialty (via a BCBS provider crosswalk), times units.
  9. custom SQL — BCBS-priced Medicare DME fee: the Medicare DME schedule amount (keyed via a BCBS-specific DME schedule map) times a BCBS-specialty-specific multiplier, times units.
  10. custom SQL — Looks up a BCBS RVU fee per unit, keyed by the rendering provider's BCBS specialty (via a provider crosswalk), an Exhibit-B flag on that specialty, the charge's TC/26 modifier, the facility's type, and the service date; multiplies by units. — when BCBSSpecialtyCategory 15 is present
  11. custom SQL — Looks up a BCBS RVU fee per unit, keyed by the rendering provider's BCBS specialty (via a provider crosswalk), an Exhibit-B flag on that specialty, the charge's TC/26 modifier, the facility's type, and the service date; multiplies by units. — when BCBSSpecialtyCategory 14 is present
  12. custom SQL — BCBS RVU-style fee lookup: resolves the billing provider's specialty and 'Exhibit B' provider flag via a BCBS-specific crosswalk, resolves the facility's type, then looks up a per-unit fee keyed by charge type+modifier(26/TC only)+specialty+ExhibitB flag+facility type+date, multiplied by Units. — when BCBSSpecialtyCategory 13 is present
  13. custom SQL — BCBS RVU-style fee lookup: resolves the billing provider's specialty and 'Exhibit B' provider flag via a BCBS-specific crosswalk, resolves the facility's type, then looks up a per-unit fee keyed by charge type+modifier(26/TC only)+specialty+ExhibitB flag+facility type+date, multiplied by Units. — when BCBSSpecialtyCategory 12 is present
  14. custom SQL — BCBS RVU-style fee lookup: resolves the billing provider's specialty and 'Exhibit B' provider flag via a BCBS-specific crosswalk, resolves the facility's type, then looks up a per-unit fee keyed by charge type+modifier(26/TC only)+specialty+ExhibitB flag+facility type+date, multiplied by Units. — when BCBSSpecialtyCategory 11 is present
  15. custom SQL — BCBS RVU-style fee lookup: resolves the billing provider's specialty and 'Exhibit B' provider flag via a BCBS-specific crosswalk, resolves the facility's type, then looks up a per-unit fee keyed by charge type+modifier(26/TC only)+specialty+ExhibitB flag+facility type+date, multiplied by Units. — when BCBSSpecialtyCategory 10 is present
  16. custom SQL — BCBS RVU-style fee lookup: resolves the billing provider's specialty and 'Exhibit B' provider flag via a BCBS-specific crosswalk, resolves the facility's type, then looks up a per-unit fee keyed by charge type+modifier(26/TC only)+specialty+ExhibitB flag+facility type+date, multiplied by Units. — when BCBSSpecialtyCategory 9 is present
  17. custom SQL — BCBS RVU-style fee lookup: resolves the billing provider's specialty and 'Exhibit B' provider flag via a BCBS-specific crosswalk, resolves the facility's type, then looks up a per-unit fee keyed by charge type+modifier(26/TC only)+specialty+ExhibitB flag+facility type+date, multiplied by Units. — when BCBSSpecialtyCategory 8 is present
  18. custom SQL — BCBS RVU-style fee lookup: resolves the billing provider's specialty and 'Exhibit B' provider flag via a BCBS-specific crosswalk, resolves the facility's type, then looks up a per-unit fee keyed by charge type+modifier(26/TC only)+specialty+ExhibitB flag+facility type+date, multiplied by Units. — when BCBSSpecialtyCategory 7 is present
  19. custom SQL — BCBS RVU-style fee lookup: resolves the billing provider's specialty and 'Exhibit B' provider flag via a BCBS-specific crosswalk, resolves the facility's type, then looks up a per-unit fee keyed by charge type+modifier(26/TC only)+specialty+ExhibitB flag+facility type+date, multiplied by Units. — when BCBSSpecialtyCategory 4 is present
  20. custom SQL — BCBS RVU-style fee lookup: resolves the billing provider's specialty and 'Exhibit B' provider flag via a BCBS-specific crosswalk, resolves the facility's type, then looks up a per-unit fee keyed by charge type+modifier(26/TC only)+specialty+ExhibitB flag+facility type+date, multiplied by Units. — when BCBSSpecialtyCategory 3 is present
  21. custom SQL — BCBS RVU-style fee lookup: resolves the billing provider's specialty and 'Exhibit B' provider flag via a BCBS-specific crosswalk, resolves the facility's type, then looks up a per-unit fee keyed by charge type+modifier(26/TC only)+specialty+ExhibitB flag+facility type+date, multiplied by Units. — when BCBSSpecialtyCategory 2 is present
  22. custom SQL — BCBS RVU-style fee lookup: resolves the billing provider's specialty and 'Exhibit B' provider flag via a BCBS-specific crosswalk, resolves the facility's type, then looks up a per-unit fee keyed by charge type+modifier(26/TC only)+specialty+ExhibitB flag+facility type+date, multiplied by Units. — when BCBSSpecialtyCategory 1 is present
  23. custom SQL — BCBS default fee-schedule pricing: resolves the provider's specialty via TransformBCBSProviderCrosswalk, resolves clinic vs facility, and looks up a per-unit fee from TransformBCBSDefaultScheduleFees keyed by charge-type code, modifier (restricted to modifiers already present in the default schedule), specialty, clinic-flag, and date, multiplied by units.
Adjustments — all apply, in order
  1. zero out charges excluded by the Bundled-Procedures schedule
  2. custom SQL — BCBS Florida POS-11 (office) carveout: adds a fixed dollar add-on on top of the already-computed allowed amount for specific specialty+CPT combinations flagged as an 'Additional' carveout under this contract.
  3. custom SQL — Applies BCBS pay-for-performance rate increases (1.01x / 1.0147x / ~1.0154x, by contract year) on top of the already-computed Allowed amount, restricted to charges whose rendering provider is in a small set of OB/GYN-family specialties (via crosswalk) and whose charge type isn't a diagnostic/facility code. — when BCBSSpecialtyCategory 3 is present; BCBSP4PExclusions 1 is absent
  4. custom SQL — Applies BCBS pay-for-performance rate increases (1.01x / 1.0147x / ~1.0154x, by contract year) on top of the already-computed Allowed amount, restricted to charges whose rendering provider is in a small set of OB/GYN-family specialties (via crosswalk) and whose charge type isn't a diagnostic/facility code. — when BCBSSpecialtyCategory 10 is present; BCBSP4PExclusions 1 is absent
  5. custom SQL — BCBS pay-for-performance bonus: for OB/Gyn-Oncology/Maternal-Fetal-Medicine specialties (a fixed list of specialty-category IDs) and non-facility charge types, multiplies the already-priced {Allowed} amount by a small stepped increase factor (1%, 1.47%, or 1.5352%) during specific contract-year bonus windows; outside those windows or for other specialties/dates, the charge is left unadjusted. — when BCBSSpecialtyCategory 4 is present; BCBSP4PExclusions 1 is absent
  6. custom SQL — A time-tiered pay-for-performance bonus (1%-1.54%, depending on contract year) applied on top of the already-computed allowed amount for BCBS charges billed by providers in six OB/GYN-related specialties, excluding charge types starting with 7, 8, or a letter. — when BCBSSpecialtyCategory 11 is present; BCBSP4PExclusions 1 is absent
  7. custom SQL — A BCBS pay-for-performance (P4P) escalator: increases the already-computed Allowed amount by a small percentage (1.01x-1.015x, varying by contract year) for charges billed by specific women's-health specialties, excluding codes starting with 7, 8, or a letter. — when BCBSSpecialtyCategory 7 is present; BCBSP4PExclusions 1 is absent
  8. custom SQL — BCBS pay-for-performance (P4P) escalator: for a defined set of OB/GYN-related specialties (Gynecology Oncology, Maternal Fetal Medicine, OB/GYN), boosts the already-computed allowed amount by 1.0%-1.51% depending on which contract year window the service date falls in, excluding certain charge types. — when BCBSSpecialtyCategory 12 is present; BCBSP4PExclusions 1 is absent
  9. custom SQL — Flat 15% across-the-board reduction to the already-priced allowed amount, except for a fixed list of carve-outs: TC/AS-modifier charges, alpha-prefixed codes, PT/OT codes (95xxx), lab (80047-89398), radiology (70010-79999), and various immunization/infusion/cardio ranges (90281-90470, 90475-90749, 93000-93278), which are left unadjusted. — when IsMidLevel Yes is present
  10. modifier 80 present → 16% of the running amount
  11. modifier AS present → 16% of the running amount
  12. modifier 52 present → 50% of the running amount
  13. modifier 25 present → 50% of the running amount — when MultipleVisit Yes is present
  14. multiple-procedure reduction (contract rules) — base codes 2, 3; pays 100/50%
Cigna14 base · 1 adj
Cigna
Profee · all facilities · 2018-09-01 → 2020-09-14
Base terms — first match wins
  1. custom SQL — Prices a mid-level (non-physician) provider's charge for a Cigna-associated customer using a specialty/procedure/modifier/facility carveout table, where the specialty group is derived from a Cigna-specific taxonomy crosswalk keyed by provider. — when IsMidLevel Yes is present
  2. custom SQL — Prices a Cigna-associated charge using a general-purpose carveout table (same specialty-crosswalk pattern as the mid-level-provider variant, hash 00f8e1f47f51a38f, but against TransformCignaCarveout rather than the mid-level-specific table). — when IsMidLevel Yes is absent
  3. 100% of the Fixed-Fees fee schedule
  4. custom SQL — Cigna fee: a base RVU-schedule amount for the procedure/modifier/facility-type, multiplied by a mid-level-provider specialty-group percentage adjustment resolved from the provider's Cigna specialty-group classification. — when IsMidLevel Yes is present
  5. custom SQL — Prices a Cigna charge as (Cigna-specific RVU fee, facility-vs-nonfacility, procedure+modifier keyed) times a Cigna specialty-group percentage multiplier; specialty group resolved via the account's own taxonomy schedule. — when IsMidLevel Yes is absent
  6. 50% of billed charges — when CignaSpecialtyCategory K is present
  7. 50% of billed charges — when CignaSpecialtyCategory J is present
  8. 50% of billed charges — when CignaSpecialtyCategory I is present
  9. 50% of billed charges — when CignaSpecialtyCategory H is present
  10. 50% of billed charges — when CignaSpecialtyCategory G is present
  11. 50% of billed charges — when CignaSpecialtyCategory F is present
  12. 50% of billed charges — when CignaSpecialtyCategory E is present
  13. 50% of billed charges — when CignaSpecialtyCategory D is present
  14. 50% of billed charges — when CignaSpecialtyCategory C is present
Adjustments — all apply, in order
  1. cap each charge and the account total at 100% of billed charges
Cigna-202014 base · 1 adj
Cigna
Profee · all facilities · 2020-09-15 → 2999-12-31
Base terms — first match wins
  1. custom SQL — Prices a Cigna-associated charge using a general-purpose carveout table (same specialty-crosswalk pattern as the mid-level-provider variant, hash 00f8e1f47f51a38f, but against TransformCignaCarveout rather than the mid-level-specific table). — when IsMidLevel Yes is absent
  2. custom SQL — Prices a mid-level (non-physician) provider's charge for a Cigna-associated customer using a specialty/procedure/modifier/facility carveout table, where the specialty group is derived from a Cigna-specific taxonomy crosswalk keyed by provider. — when IsMidLevel Yes is present
  3. 100% of the Fixed-Fees fee schedule
  4. custom SQL — Cigna mid-level-provider fee: same shape as the IFP-mid-level snippet but against the non-IFP TransformCignaMidLevelRate multiplier table (the group-plan variant of the same specialty-multiplier rule). — when IsMidLevel Yes is present
  5. custom SQL — Cigna RVU-based fee: resolves the provider's Cigna specialty group (2018 taxonomy schedule), looks up a specialty/code-specific percent multiplier from TransformCignaRate, and multiplies it by the base RVU-derived amount from TransformCignaRVU (defaulting the multiplier to 1 if the code has no rate-table entry). — when IsMidLevel Yes is absent
  6. 50% of billed charges — when CignaSpecialtyCategory K is present
  7. 50% of billed charges — when CignaSpecialtyCategory J is present
  8. 50% of billed charges — when CignaSpecialtyCategory I is present
  9. 50% of billed charges — when CignaSpecialtyCategory H is present
  10. 50% of billed charges — when CignaSpecialtyCategory G is present
  11. 50% of billed charges — when CignaSpecialtyCategory F is present
  12. 50% of billed charges — when CignaSpecialtyCategory E is present
  13. 50% of billed charges — when CignaSpecialtyCategory D is present
  14. 50% of billed charges — when CignaSpecialtyCategory C is present
Adjustments — all apply, in order
  1. cap each charge and the account total at 100% of billed charges
Cigna-IFP14 base · 0 adj
Cigna IFP
Profee · all facilities · 2021-09-01 → 2999-12-31
Base terms — first match wins
  1. custom SQL — Cigna IFP mid-level-provider specialty carve-out: same specialty-group resolution as its base-physician sibling (snippet 5bb32ae6bfd5b86c), but looks up carve-out amounts from TransformCignaIFPMidLevelCarveout for services billed by mid-level (non-physician) practitioners. — when IsMidLevel Yes is present
  2. custom SQL — Cigna IFP (individual/family plan) specialty carve-out: resolves the provider's Cigna specialty group via a taxonomy-code schedule (CignaSpecialtyGroup-2018), then looks up a flat carve-out dollar amount for that specialty group + procedure code + modifier (26/TC only) + facility/non-facility from TransformCignaIFPCarveout. — when IsMidLevel Yes is absent
  3. 100% of the Fixed-Fees fee schedule
  4. custom SQL — Cigna IFP mid-level-provider fee: base Cigna RVU fee-schedule amount for the procedure/modifier/facility-flag/date, scaled by a specialty-group-specific 'IFP mid-level' percent multiplier keyed off the rendering provider's taxonomy-derived Cigna specialty group. — when IsMidLevel Yes is present
  5. custom SQL — Cigna IFP fee (non-mid-level variant): base Cigna RVU fee-schedule amount times a specialty-group-specific 'IFP' percentage multiplier — same family as the two Cigna mid-level snippets but against the standard IFP rate table. — when IsMidLevel Yes is absent
  6. 50% of billed charges — when CignaSpecialtyCategory K is present
  7. 50% of billed charges — when CignaSpecialtyCategory J is present
  8. 50% of billed charges — when CignaSpecialtyCategory I is present
  9. 50% of billed charges — when CignaSpecialtyCategory H is present
  10. 50% of billed charges — when CignaSpecialtyCategory G is present
  11. 50% of billed charges — when CignaSpecialtyCategory F is present
  12. 50% of billed charges — when CignaSpecialtyCategory E is present
  13. 50% of billed charges — when CignaSpecialtyCategory D is present
  14. 50% of billed charges — when CignaSpecialtyCategory C is present
Devoted-Health13 base · 0 adj
Devoted Health
Profee · all facilities · 2019-08-15 → 2022-11-30
Base terms — first match wins
  1. custom SQL — Looks up a fixed dollar carveout amount for a Devoted Health charge, keyed by the rendering provider's Devoted specialty (via crosswalk) and procedure code.
  2. custom SQL — Prices a charge for a Devoted Health customer by combining a specialty+procedure-specific carveout multiplier with the Medicare RVU-based transitioned amount (RVU x conversion factor), where the RVU lookup's locality/carrier are themselves resolved through a facility-to-locality crosswalk.
  3. custom SQL — Prices a lab charge for a Devoted Health customer by taking the CommonData Medicare clinical lab fee and multiplying it by a specialty+procedure-specific base rate, falling back to a specialty-level fallback rate when no code-specific rate exists.
  4. custom SQL — Prices a drug charge for a Devoted Health customer by taking the CommonData Medicare drug schedule amount and multiplying it by a specialty+procedure-specific base rate, falling back to a specialty-level fallback rate — same pattern as the Devoted lab calc (hash 2de4752d24e6e419).
  5. custom SQL — Prices a Devoted DME charge as (national Florida Medicare DME fee from CommonData) times a Devoted-specific rate multiplier, preferring a procedure-specific base-schedule multiplier and falling back to a specialty-level fallback multiplier; specialty resolved via a Devoted provider crosswalk.
  6. custom SQL — The Devoted Health analog of the DoctorsHP DME snippet for RVU-based (not DME) pricing: a Medicare RVU amount (via a customer-curated schedule map keyed by carrier/locality/facility-type) times a specialty-specific multiplier, again with a procedure-specific base rate falling back to a specialty/locality-only rate.
  7. custom SQL — Percent-of-charges pricing intended for the 'Oscar' payer, but the specialty is resolved from DevotedSpecialtyMap (not an Oscar-specific map) before being looked up in TransformOscarBilledCharges. — when DevotedSpecialtyCategory 7 is present
  8. custom SQL — Percent-of-charges pricing intended for the 'Oscar' payer, but the specialty is resolved from DevotedSpecialtyMap (not an Oscar-specific map) before being looked up in TransformOscarBilledCharges. — when DevotedSpecialtyCategory 6 is present
  9. custom SQL — Percent-of-charges pricing intended for the 'Oscar' payer, but the specialty is resolved from DevotedSpecialtyMap (not an Oscar-specific map) before being looked up in TransformOscarBilledCharges. — when DevotedSpecialtyCategory 5 is present
  10. custom SQL — Percent-of-charges pricing intended for the 'Oscar' payer, but the specialty is resolved from DevotedSpecialtyMap (not an Oscar-specific map) before being looked up in TransformOscarBilledCharges. — when DevotedSpecialtyCategory 4 is present
  11. custom SQL — Percent-of-charges pricing intended for the 'Oscar' payer, but the specialty is resolved from DevotedSpecialtyMap (not an Oscar-specific map) before being looked up in TransformOscarBilledCharges. — when DevotedSpecialtyCategory 3 is present
  12. custom SQL — Percent-of-charges pricing intended for the 'Oscar' payer, but the specialty is resolved from DevotedSpecialtyMap (not an Oscar-specific map) before being looked up in TransformOscarBilledCharges. — when DevotedSpecialtyCategory 2 is present
  13. custom SQL — Percent-of-charges pricing intended for the 'Oscar' payer, but the specialty is resolved from DevotedSpecialtyMap (not an Oscar-specific map) before being looked up in TransformOscarBilledCharges. — when DevotedSpecialtyCategory 1 is present
Devoted-Health-202314 base · 0 adj
Devoted Health
Profee · all facilities · 2022-12-01 → 2099-12-31
Base terms — first match wins
  1. custom SQL — Looks up a fixed dollar carveout amount for a Devoted Health charge, keyed by the rendering provider's Devoted specialty (via crosswalk) and procedure code.
  2. custom SQL — Prices a charge for a Devoted Health customer by combining a specialty+procedure-specific carveout multiplier with the Medicare RVU-based transitioned amount (RVU x conversion factor), where the RVU lookup's locality/carrier are themselves resolved through a facility-to-locality crosswalk.
  3. custom SQL — Prices a lab charge for a Devoted Health customer by taking the CommonData Medicare clinical lab fee and multiplying it by a specialty+procedure-specific base rate, falling back to a specialty-level fallback rate when no code-specific rate exists.
  4. custom SQL — Prices a drug charge for a Devoted Health customer by taking the CommonData Medicare drug schedule amount and multiplying it by a specialty+procedure-specific base rate, falling back to a specialty-level fallback rate — same pattern as the Devoted lab calc (hash 2de4752d24e6e419).
  5. custom SQL — Prices a Devoted drug charge as (an AWP fee looked up from the account's own fee schedule) times a Devoted rate multiplier, preferring a procedure-specific base-schedule rate and falling back to a specialty-level fallback rate; specialty via crosswalk restricted to three specific specialty IDs (1, 4, 6).
  6. custom SQL — Prices a Devoted DME charge as (national Florida Medicare DME fee from CommonData) times a Devoted-specific rate multiplier, preferring a procedure-specific base-schedule multiplier and falling back to a specialty-level fallback multiplier; specialty resolved via a Devoted provider crosswalk.
  7. custom SQL — A Devoted Health Medicare RVU fee, scaled by a specialty/locality-specific multiplier with the same base-vs-fallback preference pattern as the DoctorsHP lab variant, except here the RVU lookup's own locality is taken from whichever rate table matched (base-schedule locality preferred over fallback locality) rather than from the facility directly.
  8. custom SQL — Percent-of-charges pricing keyed by billing provider specialty for the 'Devoted' payer — same shape as the DoctorsHP snippet, sourced from DevotedSpecialtyMap and TransformDevotedBilledCharges. — when DevotedSpecialtyCategory 7 is present
  9. custom SQL — Percent-of-charges pricing keyed by billing provider specialty for the 'Devoted' payer — same shape as the DoctorsHP snippet, sourced from DevotedSpecialtyMap and TransformDevotedBilledCharges. — when DevotedSpecialtyCategory 6 is present
  10. custom SQL — Percent-of-charges pricing keyed by billing provider specialty for the 'Devoted' payer — same shape as the DoctorsHP snippet, sourced from DevotedSpecialtyMap and TransformDevotedBilledCharges. — when DevotedSpecialtyCategory 5 is present
  11. custom SQL — Percent-of-charges pricing keyed by billing provider specialty for the 'Devoted' payer — same shape as the DoctorsHP snippet, sourced from DevotedSpecialtyMap and TransformDevotedBilledCharges. — when DevotedSpecialtyCategory 4 is present
  12. custom SQL — Percent-of-charges pricing keyed by billing provider specialty for the 'Devoted' payer — same shape as the DoctorsHP snippet, sourced from DevotedSpecialtyMap and TransformDevotedBilledCharges. — when DevotedSpecialtyCategory 3 is present
  13. custom SQL — Percent-of-charges pricing keyed by billing provider specialty for the 'Devoted' payer — same shape as the DoctorsHP snippet, sourced from DevotedSpecialtyMap and TransformDevotedBilledCharges. — when DevotedSpecialtyCategory 2 is present
  14. custom SQL — Percent-of-charges pricing keyed by billing provider specialty for the 'Devoted' payer — same shape as the DoctorsHP snippet, sourced from DevotedSpecialtyMap and TransformDevotedBilledCharges. — when DevotedSpecialtyCategory 1 is present
Doctors-HP12 base · 0 adj
Doctors HP
Profee · all facilities · 2019-02-01 → 2099-12-31
Base terms — first match wins
  1. custom SQL — A flat carve-out dollar amount for DoctorsHP-insured claims, keyed by the pricing provider's specialty and procedure code (no facility/locality dimension).
  2. custom SQL — A DoctorsHP Medicare lab fee, scaled by a specialty/locality-specific multiplier that prefers a code-specific base-schedule rate and falls back to a specialty/locality-only generic multiplier when no code-specific rate exists.
  3. custom SQL — Prices a Doctors HealthCare Plan (DoctorsHP) drug charge as (national Medicare drug ASP fee from CommonData) times a DoctorsHP rate multiplier, preferring a procedure+locality-specific base rate and falling back to a specialty+locality fallback rate; specialty via crosswalk, locality via facility-locality crosswalk.
  4. custom SQL — A DoctorsHP/Devoted Medicare DME fee: the FL Medicare DME schedule amount times a specialty-and-locality-specific multiplier, preferring a procedure-specific base-schedule multiplier and falling back to a specialty/locality-only multiplier when no procedure-specific rate exists.
  5. custom SQL — DoctorsHP (payer) contracted rate: a specialty- and locality-specific percentage of the Medicare RVU-based fee, using a procedure/modifier-specific base-schedule percentage when one exists, otherwise falling back to a specialty/locality-level default percentage.
  6. custom SQL — Percent-of-charges pricing keyed by the billing provider's specialty for the 'DoctorsHP' payer: resolves ProviderID -> SpecialtyID via a specialty crosswalk, looks up that specialty's billed-charge percentage for the service date, and applies it to the charge (Percent * Charged). — when DoctorsHPSpecialtyCategory 7 is present
  7. custom SQL — Percent-of-charges pricing keyed by the billing provider's specialty for the 'DoctorsHP' payer: resolves ProviderID -> SpecialtyID via a specialty crosswalk, looks up that specialty's billed-charge percentage for the service date, and applies it to the charge (Percent * Charged). — when DoctorsHPSpecialtyCategory 6 is present
  8. custom SQL — Percent-of-charges pricing keyed by the billing provider's specialty for the 'DoctorsHP' payer: resolves ProviderID -> SpecialtyID via a specialty crosswalk, looks up that specialty's billed-charge percentage for the service date, and applies it to the charge (Percent * Charged). — when DoctorsHPSpecialtyCategory 5 is present
  9. custom SQL — Percent-of-charges pricing keyed by the billing provider's specialty for the 'DoctorsHP' payer: resolves ProviderID -> SpecialtyID via a specialty crosswalk, looks up that specialty's billed-charge percentage for the service date, and applies it to the charge (Percent * Charged). — when DoctorsHPSpecialtyCategory 4 is present
  10. custom SQL — Percent-of-charges pricing keyed by the billing provider's specialty for the 'DoctorsHP' payer: resolves ProviderID -> SpecialtyID via a specialty crosswalk, looks up that specialty's billed-charge percentage for the service date, and applies it to the charge (Percent * Charged). — when DoctorsHPSpecialtyCategory 3 is present
  11. custom SQL — Percent-of-charges pricing keyed by the billing provider's specialty for the 'DoctorsHP' payer: resolves ProviderID -> SpecialtyID via a specialty crosswalk, looks up that specialty's billed-charge percentage for the service date, and applies it to the charge (Percent * Charged). — when DoctorsHPSpecialtyCategory 2 is present
  12. custom SQL — Percent-of-charges pricing keyed by the billing provider's specialty for the 'DoctorsHP' payer: resolves ProviderID -> SpecialtyID via a specialty crosswalk, looks up that specialty's billed-charge percentage for the service date, and applies it to the charge (Percent * Charged). — when DoctorsHPSpecialtyCategory 1 is present
FL-Medicaid2 base · 1 adj
Aetna Medicaid
Profee · all facilities · 2018-01-01 → 2999-12-31
Base terms — first match wins
  1. custom SQL — Florida Medicaid carve-out fee: a taxonomy-code- and office/facility-specific rate for the procedure, with patient age-range and modifier-fallback matching, times units.
  2. 100% of billed charges
Adjustments — all apply, in order
  1. cap each charge and the account total at 100% of billed charges
Humana13 base · 0 adj
Humana
Profee · all facilities · 2017-12-01 → 2099-12-31
Base terms — first match wins
  1. custom SQL — Humana commercial 'carveout' fee lookup: resolves the billing provider's Humana specialty and the facility's Humana region, then looks up a flat carveout dollar amount keyed by specialty+region+procedure code+modifier+date range. — when HumanaSpecialtyCategory 11 is present
  2. custom SQL — Humana commercial 'carveout' fee lookup: resolves the billing provider's Humana specialty and the facility's Humana region, then looks up a flat carveout dollar amount keyed by specialty+region+procedure code+modifier+date range. — when HumanaSpecialtyCategory 10 is present
  3. custom SQL — Humana commercial 'carveout' fee lookup: resolves the billing provider's Humana specialty and the facility's Humana region, then looks up a flat carveout dollar amount keyed by specialty+region+procedure code+modifier+date range. — when HumanaSpecialtyCategory 9 is present
  4. custom SQL — Humana commercial 'carveout' fee lookup: resolves the billing provider's Humana specialty and the facility's Humana region, then looks up a flat carveout dollar amount keyed by specialty+region+procedure code+modifier+date range. — when HumanaSpecialtyCategory 8 is present
  5. custom SQL — Humana commercial 'carveout' fee lookup: resolves the billing provider's Humana specialty and the facility's Humana region, then looks up a flat carveout dollar amount keyed by specialty+region+procedure code+modifier+date range. — when HumanaSpecialtyCategory 7 is present
  6. custom SQL — Humana commercial 'carveout' fee lookup: resolves the billing provider's Humana specialty and the facility's Humana region, then looks up a flat carveout dollar amount keyed by specialty+region+procedure code+modifier+date range. — when HumanaSpecialtyCategory 6 is present
  7. custom SQL — Humana commercial 'carveout' fee lookup: resolves the billing provider's Humana specialty and the facility's Humana region, then looks up a flat carveout dollar amount keyed by specialty+region+procedure code+modifier+date range. — when HumanaSpecialtyCategory 5 is present
  8. custom SQL — Humana commercial 'carveout' fee lookup: resolves the billing provider's Humana specialty and the facility's Humana region, then looks up a flat carveout dollar amount keyed by specialty+region+procedure code+modifier+date range. — when HumanaSpecialtyCategory 4 is present
  9. custom SQL — Humana commercial 'carveout' fee lookup: resolves the billing provider's Humana specialty and the facility's Humana region, then looks up a flat carveout dollar amount keyed by specialty+region+procedure code+modifier+date range. — when HumanaSpecialtyCategory 3 is present
  10. custom SQL — Humana commercial 'carveout' fee lookup: resolves the billing provider's Humana specialty and the facility's Humana region, then looks up a flat carveout dollar amount keyed by specialty+region+procedure code+modifier+date range. — when HumanaSpecialtyCategory 2 is present
  11. custom SQL — Humana commercial 'carveout' fee lookup: resolves the billing provider's Humana specialty and the facility's Humana region, then looks up a flat carveout dollar amount keyed by specialty+region+procedure code+modifier+date range. — when HumanaSpecialtyCategory 1 is present
  12. custom SQL — Humana mid-level-provider negotiated fee-schedule amount for a procedure, keyed by rendering provider's specialty, a Humana contract region, facility flag, and modifier. — when IsMidLevel Yes is present
  13. custom SQL — Humana (non-mid-level) negotiated fee-schedule amount for a procedure, keyed by rendering provider's specialty, Humana contract region, facility flag, and modifier. — when IsMidLevel Yes is absent
Humana-Medicare8 base · 0 adj
Humana Medicare
Profee · all facilities · 2018-03-01 → 2020-11-30
Base terms — first match wins
  1. custom SQL — Humana Medicare Advantage (standard) fee-schedule amount lookup: resolves provider specialty and facility region/facility-flag via Humana-specific crosswalks, then looks up a flat schedule amount keyed by specialty+region+procedure code+modifier+isFacility+date range. — when HumanaSpecialtyCategory 8 is present
  2. custom SQL — Humana Medicare Advantage (standard) fee-schedule amount lookup: resolves provider specialty and facility region/facility-flag via Humana-specific crosswalks, then looks up a flat schedule amount keyed by specialty+region+procedure code+modifier+isFacility+date range. — when HumanaSpecialtyCategory 7 is present
  3. custom SQL — Humana Medicare Advantage (standard) fee-schedule amount lookup: resolves provider specialty and facility region/facility-flag via Humana-specific crosswalks, then looks up a flat schedule amount keyed by specialty+region+procedure code+modifier+isFacility+date range. — when HumanaSpecialtyCategory 6 is present
  4. custom SQL — Humana Medicare Advantage (standard) fee-schedule amount lookup: resolves provider specialty and facility region/facility-flag via Humana-specific crosswalks, then looks up a flat schedule amount keyed by specialty+region+procedure code+modifier+isFacility+date range. — when HumanaSpecialtyCategory 5 is present
  5. custom SQL — Humana Medicare Advantage (standard) fee-schedule amount lookup: resolves provider specialty and facility region/facility-flag via Humana-specific crosswalks, then looks up a flat schedule amount keyed by specialty+region+procedure code+modifier+isFacility+date range. — when HumanaSpecialtyCategory 4 is present
  6. custom SQL — Humana Medicare Advantage (standard) fee-schedule amount lookup: resolves provider specialty and facility region/facility-flag via Humana-specific crosswalks, then looks up a flat schedule amount keyed by specialty+region+procedure code+modifier+isFacility+date range. — when HumanaSpecialtyCategory 3 is present
  7. custom SQL — Humana Medicare Advantage (standard) fee-schedule amount lookup: resolves provider specialty and facility region/facility-flag via Humana-specific crosswalks, then looks up a flat schedule amount keyed by specialty+region+procedure code+modifier+isFacility+date range. — when HumanaSpecialtyCategory 2 is present
  8. custom SQL — Humana Medicare Advantage (standard) fee-schedule amount lookup: resolves provider specialty and facility region/facility-flag via Humana-specific crosswalks, then looks up a flat schedule amount keyed by specialty+region+procedure code+modifier+isFacility+date range. — when HumanaSpecialtyCategory 1 is present
Humana-Medicare-HMO8 base · 1 adj
Humana Medicare
Profee · all facilities · 2020-12-01 → 2099-12-31
Base terms — first match wins
  1. custom SQL — Humana Medicare HMO fee-schedule amount lookup — identical shape to hash 6415366c4bee9b24 (standard Humana Medicare) but sourced from the HumanaMedicareHMOScheduleAmount table. — when HumanaSpecialtyCategory 8 is present
  2. custom SQL — Humana Medicare HMO fee-schedule amount lookup — identical shape to hash 6415366c4bee9b24 (standard Humana Medicare) but sourced from the HumanaMedicareHMOScheduleAmount table. — when HumanaSpecialtyCategory 7 is present
  3. custom SQL — Humana Medicare HMO fee-schedule amount lookup — identical shape to hash 6415366c4bee9b24 (standard Humana Medicare) but sourced from the HumanaMedicareHMOScheduleAmount table. — when HumanaSpecialtyCategory 6 is present
  4. custom SQL — Humana Medicare HMO fee-schedule amount lookup — identical shape to hash 6415366c4bee9b24 (standard Humana Medicare) but sourced from the HumanaMedicareHMOScheduleAmount table. — when HumanaSpecialtyCategory 5 is present
  5. custom SQL — Humana Medicare HMO fee-schedule amount lookup — identical shape to hash 6415366c4bee9b24 (standard Humana Medicare) but sourced from the HumanaMedicareHMOScheduleAmount table. — when HumanaSpecialtyCategory 4 is present
  6. custom SQL — Humana Medicare HMO fee-schedule amount lookup — identical shape to hash 6415366c4bee9b24 (standard Humana Medicare) but sourced from the HumanaMedicareHMOScheduleAmount table. — when HumanaSpecialtyCategory 3 is present
  7. custom SQL — Humana Medicare HMO fee-schedule amount lookup — identical shape to hash 6415366c4bee9b24 (standard Humana Medicare) but sourced from the HumanaMedicareHMOScheduleAmount table. — when HumanaSpecialtyCategory 2 is present
  8. custom SQL — Humana Medicare HMO fee-schedule amount lookup — identical shape to hash 6415366c4bee9b24 (standard Humana Medicare) but sourced from the HumanaMedicareHMOScheduleAmount table. — when HumanaSpecialtyCategory 1 is present
Adjustments — all apply, in order
  1. cap each charge and the account total at 100% of billed charges
Humana-Medicare-PPO8 base · 1 adj
Humana Medicare PPO
Profee · all facilities · 2021-01-01 → 2099-12-31
Base terms — first match wins
  1. custom SQL — Humana Medicare PPO fee-schedule amount lookup — identical shape to hashes 6415366c4bee9b24/f2fb13e8bca2d62c but sourced from HumanaMedicarePPOScheduleAmount. — when HumanaSpecialtyCategory 8 is present
  2. custom SQL — Humana Medicare PPO fee-schedule amount lookup — identical shape to hashes 6415366c4bee9b24/f2fb13e8bca2d62c but sourced from HumanaMedicarePPOScheduleAmount. — when HumanaSpecialtyCategory 7 is present
  3. custom SQL — Humana Medicare PPO fee-schedule amount lookup — identical shape to hashes 6415366c4bee9b24/f2fb13e8bca2d62c but sourced from HumanaMedicarePPOScheduleAmount. — when HumanaSpecialtyCategory 6 is present
  4. custom SQL — Humana Medicare PPO fee-schedule amount lookup — identical shape to hashes 6415366c4bee9b24/f2fb13e8bca2d62c but sourced from HumanaMedicarePPOScheduleAmount. — when HumanaSpecialtyCategory 5 is present
  5. custom SQL — Humana Medicare PPO fee-schedule amount lookup — identical shape to hashes 6415366c4bee9b24/f2fb13e8bca2d62c but sourced from HumanaMedicarePPOScheduleAmount. — when HumanaSpecialtyCategory 4 is present
  6. custom SQL — Humana Medicare PPO fee-schedule amount, keyed by the provider's Humana specialty (crosswalk), the facility's Humana region and facility/office flag, procedure, modifier, and date. — when HumanaSpecialtyCategory 3 is present
  7. custom SQL — Humana Medicare PPO fee-schedule amount lookup — identical shape to hashes 6415366c4bee9b24/f2fb13e8bca2d62c but sourced from HumanaMedicarePPOScheduleAmount. — when HumanaSpecialtyCategory 2 is present
  8. custom SQL — Humana Medicare PPO fee-schedule amount lookup — identical shape to hashes 6415366c4bee9b24/f2fb13e8bca2d62c but sourced from HumanaMedicarePPOScheduleAmount. — when HumanaSpecialtyCategory 1 is present
Adjustments — all apply, in order
  1. cap each charge and the account total at 100% of billed charges
Medicare5 base · 12 adj
Medicare
Profee · all facilities · 2000-01-01 → 9999-12-31
Base terms — first match wins
  1. 100% of the Medicare-Drug fee schedule
  2. 100% of the Medicare-Lab fee schedule
  3. 100% of the Medicare-DME fee schedule
  4. 100% of the Medicare-RVU-Hospital/ASC fee schedule — when POS 11 is absent
  5. 100% of the Medicare-RVU-Clinic fee schedule — when POS 11 is present
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
Memorial-Health-Network6 base · 12 adj
Memorial Health Network
Profee · all facilities · 2018-02-14 → 2999-12-31
Base terms — first match wins
  1. custom SQL — A flat carve-out dollar amount for Memorial Health Network claims, keyed by provider specialty, procedure code, and a normalized assistant-surgeon/co-surgeon modifier bucket (80, AS, or blank).
  2. custom SQL — Memorial Health Network flat-fee carveout: returns a flat dollar Rate for the procedure code, keyed only by code and effective date -- no specialty, facility, or modifier dimension despite specialty/provider variables being computed.
  3. custom SQL — Memorial Health Network lab pricing: resolves provider specialty (MemorialHealthNetworkSpecialtyMap), looks up the Medicare-Lab FeeScheduleRecord amount, and multiplies by a specialty-specific rate from TransformMemorialHealthNetworkBilledCharges.
  4. custom SQL — Memorial Health Network drug fee: resolves provider specialty (MemorialHealthNetworkSpecialtyMap), looks up the Medicare-Drug fee-schedule amount for the code, and multiplies it by a specialty-level percent-of-charge rate from TransformMemorialHealthNetworkBilledCharges.
  5. custom SQL — Memorial Health Network DME rate: the Medicare DME fee-schedule amount for a facility, scaled by a provider-specialty-specific percent-of-charge rate negotiated under this contract.
  6. custom SQL — Prices a Memorial Health Network charge as (Medicare RVU fee from the account's own schedule) times a Memorial-specific 'percent of billed charge' rate keyed by rendering-provider specialty (via crosswalk).
Adjustments — all apply, in order
  1. multiple-procedure reduction (contract rules) — base codes 2; pays 100% — when MemorialHealthNetworkSpecialtyCategory 1 is present
  2. multiple-procedure reduction (contract rules) — base codes 2; pays 100% — when MemorialHealthNetworkSpecialtyCategory 2 is present
  3. multiple-procedure reduction (contract rules) — base codes 2; pays 100% — when MemorialHealthNetworkSpecialtyCategory 3 is present
  4. multiple-procedure reduction (contract rules) — base codes 2; pays 100% — when MemorialHealthNetworkSpecialtyCategory 4 is present
  5. multiple-procedure reduction (contract rules) — base codes 2; pays 100% — when MemorialHealthNetworkSpecialtyCategory 5 is present
  6. multiple-procedure reduction (contract rules) — base codes 2; pays 100% — when MemorialHealthNetworkSpecialtyCategory 6 is present
  7. multiple-procedure reduction (contract rules) — base codes 2; pays 100% — when MemorialHealthNetworkSpecialtyCategory 7 is present
  8. multiple-procedure reduction (contract rules) — base codes 2; pays 100% — when MemorialHealthNetworkSpecialtyCategory 8 is present
  9. multiple-procedure reduction (contract rules) — base codes 2; pays 100% — when MemorialHealthNetworkSpecialtyCategory 9 is present
  10. multiple-procedure reduction (contract rules) — base codes 2; pays 100% — when MemorialHealthNetworkSpecialtyCategory 10 is present
  11. multiple-procedure reduction (contract rules) — base codes 2; pays 100% — when MemorialHealthNetworkSpecialtyCategory 11 is present
  12. multiple-procedure reduction (contract rules) — base codes 2; pays 100% — when MemorialHealthNetworkSpecialtyCategory 12 is present
Molina7 base · 1 adj
Molina
Profee · all facilities · 2021-01-01 → 2999-12-31
Base terms — first match wins
  1. custom SQL — Prices a drug charge off the Medicare drug (ASP) fee schedule, then rescales it by a provider-specialty-specific rate multiplier from a customer 'Molina' incentive/carveout crosswalk, keyed by the provider's specialty.
  2. custom SQL — Prices a DME charge for a Molina-associated customer by taking the Medicare-DME fee-schedule amount and multiplying it by a provider-specialty rate multiplier from the Molina specialty crosswalk — same pattern as the Sunshine DME/drug calcs but for Molina.
  3. custom SQL — Prices a lab charge off the Medicare clinical-lab fee schedule, then rescales it by a provider-specialty-specific rate multiplier from a customer 'Molina' crosswalk -- the lab-fee sibling of idx49 (which does the same for drugs).
  4. custom SQL — Prices a Molina charge as (Medicare RVU fee looked up from the account's own fee schedule) times a Molina-specific specialty rate multiplier, where specialty is resolved via a Molina provider crosswalk and facility type/locality via a facility-locality crosswalk.
  5. custom SQL — 110% of the Florida Medicaid fee-schedule rate for a procedure, keyed by rendering provider's taxonomy code, office vs. non-office setting, modifier, and patient age range.
  6. 110% of billed charges — when MolinaSpecialtyCategory 2 is present
  7. 110% of billed charges — when MolinaSpecialtyCategory 1 is present
Adjustments — all apply, in order
  1. cap each charge and the account total at 100% of billed charges
MolinaChargeAnalysis7 base · 1 adj
MolinaChargeAnalysis
Profee · all facilities · 2021-01-01 → 2999-12-31
Base terms — first match wins
  1. custom SQL — Prices a drug charge off the Medicare drug (ASP) fee schedule, then rescales it by a provider-specialty-specific rate multiplier from a customer 'Molina' incentive/carveout crosswalk, keyed by the provider's specialty.
  2. custom SQL — Prices a DME charge for a Molina-associated customer by taking the Medicare-DME fee-schedule amount and multiplying it by a provider-specialty rate multiplier from the Molina specialty crosswalk — same pattern as the Sunshine DME/drug calcs but for Molina.
  3. custom SQL — Prices a lab charge off the Medicare clinical-lab fee schedule, then rescales it by a provider-specialty-specific rate multiplier from a customer 'Molina' crosswalk -- the lab-fee sibling of idx49 (which does the same for drugs).
  4. custom SQL — Prices a Molina charge as (Medicare RVU fee looked up from the account's own fee schedule) times a Molina-specific specialty rate multiplier, where specialty is resolved via a Molina provider crosswalk and facility type/locality via a facility-locality crosswalk.
  5. custom SQL — 110% of the Florida Medicaid fee-schedule amount for the charge's procedure/modifier/office-vs-facility/date — a Medicaid 'carve-out' uplift.
  6. 110% of billed charges — when MolinaSpecialtyCategory 2 is present
  7. 110% of billed charges — when MolinaSpecialtyCategory 1 is present
Adjustments — all apply, in order
  1. cap each charge and the account total at 100% of billed charges
MolinaMedicare4 base · 14 adj
MolinaMedicare
Profee · all facilities · 2021-01-01 → 2999-12-31
Base terms — first match wins
  1. custom SQL — Prices a drug charge off the Medicare drug (ASP) fee schedule, then rescales it by a provider-specialty-specific rate multiplier from a customer 'Molina' incentive/carveout crosswalk, keyed by the provider's specialty.
  2. custom SQL — Molina DME rate: the Medicare DME fee-schedule amount for a facility, scaled by a provider-specialty-specific rate negotiated under this contract.
  3. custom SQL — Prices a lab charge off the Medicare clinical-lab fee schedule, then rescales it by a provider-specialty-specific rate multiplier from a customer 'Molina' crosswalk -- the lab-fee sibling of idx49 (which does the same for drugs).
  4. custom SQL — Molina Medicare-RVU multiplier: resolves provider specialty (MolinaSpecialtyMap) and facility type (SourceFacilityLocalityMap), looks up the Medicare-RVU fee-schedule amount for that facility type/code, and multiplies it by a specialty-level (not procedure-specific) rate from TransformMolinaRate.
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 — Reduces the already-computed allowed amount to 85% of itself for charges that are not TC/AS-modified and whose procedure code falls outside a hardcoded set of lab, radiology, immunization, cardiology-diagnostic, and alphanumeric-prefixed code ranges — a blanket markdown for 'everything except these carve-outs'. — when IsMidLevel Yes is present
  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 — when MolinaSpecialtyCategory 1 is present
  8. modifier 62 present → 62.5% of the running amount — when MolinaSpecialtyCategory 2 is present
  9. modifier 80 present → 16% of the running amount
  10. modifier 81 present → 16% of the running amount
  11. modifier 82 present → 16% of the running amount
  12. modifier AS present → 13.6% of the running amount
  13. modifier 78 present → 69% of the running amount
  14. cap each charge and the account total at 100% of billed charges
Oscar7 base · 9 adj
Oscar
Profee · all facilities · 2020-01-01 → 2999-12-31
Base terms — first match wins
  1. custom SQL — Prices an Oscar immunization/lab charge as (a fixed 'Fixed-Fees-Immunizations' schedule amount) times an Oscar-specific specialty rate multiplier, specialty resolved via crosswalk.
  2. custom SQL — Looks up a fixed dollar carveout amount for an Oscar charge, keyed by rendering-provider specialty (via crosswalk) and procedure code.
  3. custom SQL — An Oscar/Sunshine Health lab fee equal to the plan's Medicare-Lab fee-schedule amount (facility-scoped) times a specialty-and-code-specific rate multiplier sourced from a custom Oscar 'rate card' keyed by the rendering provider's specialty.
  4. custom SQL — Oscar Health drug pricing: resolves provider specialty (OscarSpecialtyMap), looks up the Medicare-Drug FeeScheduleRecord amount, and multiplies by an Oscar-specific rate from TransformOscarRate.
  5. custom SQL — OSCAR/Sunshine-style DME price: looks up the provider's specialty (OscarSpecialtyMap), multiplies a specialty+code+modifier rate (TransformOscarRate) by the Medicare-DME FeeScheduleRecord per-unit fee for the code.
  6. custom SQL — Same Oscar/Sunshine rate-card pattern as the lab variant, but pricing the Medicare RVU-based fee for the facility's resolved locality/facility-type, again scaled by the specialty rate multiplier.
  7. custom SQL — A percent-of-charges amount for Oscar Health claims, where the percentage is looked up per provider specialty (rather than per procedure code).
Adjustments — all apply, in order
  1. multiple-procedure reduction (contract rules) — base codes 2; pays 100% — when OscarSpecialtyCategory 1 is present
  2. multiple-procedure reduction (contract rules) — base codes 2; pays 100% — when OscarSpecialtyCategory 2 is present
  3. multiple-procedure reduction (contract rules) — base codes 2; pays 100% — when OscarSpecialtyCategory 3 is present
  4. multiple-procedure reduction (contract rules) — base codes 2; pays 100% — when OscarSpecialtyCategory 4 is present
  5. multiple-procedure reduction (contract rules) — base codes 2; pays 100% — when OscarSpecialtyCategory 5 is present
  6. multiple-procedure reduction (contract rules) — base codes 2; pays 100% — when OscarSpecialtyCategory 6 is present
  7. multiple-procedure reduction (contract rules) — base codes 2; pays 100% — when OscarSpecialtyCategory 7 is present
  8. multiple-procedure reduction (contract rules) — base codes 2; pays 100% — when OscarSpecialtyCategory 8 is present
  9. multiple-procedure reduction (contract rules) — base codes 2; pays 100% — when OscarSpecialtyCategory 9 is present
Sunshine13 base · 1 adj
Sunshine
Profee · all facilities · 2022-01-01 → 2023-12-31
Base terms — first match wins
  1. 123% of the Carve-Out fee schedule — when SunshineSpecialtyCategory 4 is present
  2. 118% of the Carve-Out fee schedule — when SunshineSpecialtyCategory 3 is present
  3. 113% of the Carve-Out fee schedule — when SunshineSpecialtyCategory 2 is present
  4. 103% of the Carve-Out fee schedule — when SunshineSpecialtyCategory 1 is present
  5. custom SQL — Prices a drug charge for a Sunshine Health-associated customer by taking the Medicare fee-schedule drug amount and multiplying it by a provider-specialty-specific rate multiplier resolved through the customer's Sunshine specialty crosswalk.
  6. custom SQL — Prices a DME charge for a Sunshine Health-associated customer by taking the Medicare-DME fee-schedule amount and multiplying it by a provider-specialty rate multiplier from the Sunshine specialty crosswalk — same pattern as the Sunshine drug calc (hash 52485f8a96ba2eed) but for DME.
  7. custom SQL — Prices a lab charge off the Medicare clinical-lab fee schedule for the given facility/date/procedure/modifier, then rescales it by a provider-specialty-specific rate multiplier from a customer 'Sunshine' incentive-program table, keyed by the provider's specialty (resolved via a customer specialty crosswalk).
  8. custom SQL — Prices a professional/technical-component charge off the Medicare RVU fee schedule (keyed by resolved facility type and locality), then rescales it by a provider-specialty-specific rate multiplier from the same customer 'Sunshine' incentive-program crosswalk used in idx40 (Lab sibling).
  9. 40% of billed charges — when SunshineSpecialtyCategory 5 is present
  10. 40% of billed charges — when SunshineSpecialtyCategory 4 is present
  11. 40% of billed charges — when SunshineSpecialtyCategory 3 is present
  12. 40% of billed charges — when SunshineSpecialtyCategory 2 is present
  13. 40% of billed charges — when SunshineSpecialtyCategory 1 is present
Adjustments — all apply, in order
  1. cap each charge and the account total at 100% of billed charges
Sunshine-202411 base · 2 adj
Sunshine
Profee · all facilities · 2024-01-01 → 2999-12-31
Base terms — first match wins
  1. 100% of the Fixed-Fees-ProcedureCode fee schedule
  2. 80% of the Carve-Out fee schedule — when SunshineSpecialtyCategory 5 is present
  3. 123% of the Carve-Out fee schedule — when SunshineSpecialtyCategory 4 is present
  4. 118% of the Carve-Out fee schedule — when SunshineSpecialtyCategory 3 is present
  5. 113% of the Carve-Out fee schedule — when SunshineSpecialtyCategory 2 is present
  6. 103% of the Carve-Out fee schedule — when SunshineSpecialtyCategory 1 is present
  7. custom SQL — Sunshine Health drug rate: the Medicare drug fee-schedule amount for a facility, scaled by a provider-specialty-specific rate negotiated under this contract.
  8. custom SQL — Prices a DME charge for a Sunshine Health-associated customer by taking the Medicare-DME fee-schedule amount and multiplying it by a provider-specialty rate multiplier from the Sunshine specialty crosswalk — same pattern as the Sunshine drug calc (hash 52485f8a96ba2eed) but for DME.
  9. custom SQL — Prices a lab charge off the Medicare clinical-lab fee schedule for the given facility/date/procedure/modifier, then rescales it by a provider-specialty-specific rate multiplier from a customer 'Sunshine' incentive-program table, keyed by the provider's specialty (resolved via a customer specialty crosswalk).
  10. custom SQL — Prices a professional/technical-component charge off the Medicare RVU fee schedule (keyed by resolved facility type and locality), then rescales it by a provider-specialty-specific rate multiplier from the same customer 'Sunshine' incentive-program crosswalk used in idx40 (Lab sibling).
  11. 40% of billed charges
Adjustments — all apply, in order
  1. cap each charge and the account total at 100% of billed charges — when PlaceOfServiceGroup Clinic is present
  2. cap each charge and the account total at 100% of billed charges — when PlaceOfServiceGroup Clinic is absent
Sunshine-Medicare4 base · 17 adj
Sunshine Medicare
Profee · all facilities · 2019-01-01 → 2999-12-31
Base terms — first match wins
  1. custom SQL — Sunshine Health lab rate: the Medicare clinical-lab fee-schedule amount for a facility, scaled by a provider-specialty-specific rate negotiated under this contract.
  2. custom SQL — A Medicare drug fee for Sunshine Health, scaled by a specialty-specific rate multiplier -- same shape as the RVU variant (07aba51389aa16d8) but sourced from the Medicare-Drug fee schedule instead of Medicare-RVU.
  3. custom SQL — DME per-unit Medicare fee-schedule amount multiplied by a rendering-provider-specialty-specific rate factor sourced from a state-Medicaid (Sunshine) specialty-to-rate crosswalk.
  4. custom SQL — Sunshine Health Medicare-referenced pricing: resolves provider specialty (SunshineSpecialtyMap) and facility type (SourceFacilityLocalityMap), looks up the Medicare-RVU FeeScheduleRecord amount for that facility/procedure/modifier, and multiplies by a Sunshine specialty-specific rate factor from TransformSunshineMedicareRate.
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 — Reduces the already-computed allowed amount to 85% of itself for charges that are not TC/AS-modified and whose procedure code falls outside a hardcoded set of lab, radiology, immunization, cardiology-diagnostic, and alphanumeric-prefixed code ranges — a blanket markdown for 'everything except these carve-outs'. — when IsMidLevel Yes is present
  4. modifier 50 present → 150% of the running amount
  5. modifier 50 present → 150% of the running amount — when SunshineSpecialtyCategory 1 is present
  6. modifier 50 present → 150% of the running amount — when SunshineSpecialtyCategory 2 is present
  7. modifier 50 present → 150% of the running amount — when SunshineSpecialtyCategory 3 is present
  8. modifier 50 present → 150% of the running amount — when SunshineSpecialtyCategory 4 is present
  9. modifier 50 present → 150% of the running amount — when SunshineSpecialtyCategory 5 is present
  10. modifier 22 present → 135% of the running amount
  11. modifier 52 present → 90% of the running amount
  12. modifier 62 present → 62.5% 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 → 13.6% of the running amount
  17. modifier 78 present → 69% of the running amount
Sunshine20219 base · 1 adj
Sunshine
Profee · all facilities · 2019-01-01 → 2021-12-31
Base terms — first match wins
  1. custom SQL — Prices a drug charge for a Sunshine Health-associated customer by taking the Medicare fee-schedule drug amount and multiplying it by a provider-specialty-specific rate multiplier resolved through the customer's Sunshine specialty crosswalk.
  2. custom SQL — Prices a DME charge for a Sunshine Health-associated customer by taking the Medicare-DME fee-schedule amount and multiplying it by a provider-specialty rate multiplier from the Sunshine specialty crosswalk — same pattern as the Sunshine drug calc (hash 52485f8a96ba2eed) but for DME.
  3. custom SQL — Prices a lab charge off the Medicare clinical-lab fee schedule for the given facility/date/procedure/modifier, then rescales it by a provider-specialty-specific rate multiplier from a customer 'Sunshine' incentive-program table, keyed by the provider's specialty (resolved via a customer specialty crosswalk).
  4. custom SQL — Prices a professional/technical-component charge off the Medicare RVU fee schedule (keyed by resolved facility type and locality), then rescales it by a provider-specialty-specific rate multiplier from the same customer 'Sunshine' incentive-program crosswalk used in idx40 (Lab sibling).
  5. 40% of billed charges — when SunshineSpecialtyCategory 5 is present
  6. 40% of billed charges — when SunshineSpecialtyCategory 4 is present
  7. 40% of billed charges — when SunshineSpecialtyCategory 3 is present
  8. 40% of billed charges — when SunshineSpecialtyCategory 2 is present
  9. 40% of billed charges — when SunshineSpecialtyCategory 1 is present
Adjustments — all apply, in order
  1. cap each charge and the account total at 100% of billed charges
United-Healthcare6 base · 9 adj
United Healthcare
Profee · all facilities · 2019-02-01 → 2021-02-28
Base terms — first match wins
  1. custom SQL — A United Healthcare 'carve-out' fee: a flat schedule amount keyed by the rendering provider's United specialty group (via a taxonomy-code crosswalk), facility type, procedure, modifier, and date.
  2. custom SQL — Same United specialty-group-keyed fee-schedule pattern as the carve-out snippet, applied to a separate 'injectable drugs' fee table.
  3. custom SQL — United Drug fee: resolves the provider's United specialty group (2019 taxonomy schedule) and facility type, then looks up the matching drug fee from TransformUnitedDrug by specialty group/facility/procedure/modifier/date.
  4. custom SQL — United Lab fee: resolves the provider's United specialty group (via a 2019 taxonomy schedule) and facility type, then looks up the matching lab fee from TransformUnitedLab by specialty group/facility/procedure/modifier/date.
  5. custom SQL — Looks up a United Healthcare DME fee, keyed by the rendering provider's specialty group (resolved via the account's own taxonomy schedule, not a crosswalk), facility Clinic/Hospital type, procedure code, and a normalized single-letter modifier (KM/KN/NU/RR/UE).
  6. custom SQL — Same United specialty-group-keyed fee-schedule pattern once more, against a general United RVU fee schedule (the third variant of the carve-out/injectable/RVU family).
Adjustments — all apply, in order
  1. multiple-procedure reduction (contract rules) — base codes 2 — when UnitedSpecialtyCategory A is present
  2. multiple-procedure reduction (contract rules) — base codes 2 — when UnitedSpecialtyCategory B is present
  3. multiple-procedure reduction (contract rules) — base codes 2 — when UnitedSpecialtyCategory C is present
  4. multiple-procedure reduction (contract rules) — base codes 2 — when UnitedSpecialtyCategory D is present
  5. multiple-procedure reduction (contract rules) — base codes 2 — when UnitedSpecialtyCategory E is present
  6. multiple-procedure reduction (contract rules) — base codes 2 — when UnitedSpecialtyCategory F is present
  7. multiple-procedure reduction (contract rules) — base codes 2 — when UnitedSpecialtyCategory G is present
  8. multiple-procedure reduction (contract rules) — base codes 2 — when UnitedSpecialtyCategory H is present
  9. modifier 80 present → 16% of the running amount
United-Healthcare-20217 base · 9 adj
United Healthcare
Profee · all facilities · 2021-03-01 → 2022-02-28
Base terms — first match wins
  1. custom SQL — Prices a charge from a United Healthcare 2021 'carveout' rate table, keyed by the billing provider's specialty group (resolved via a native schedule lookup), procedure code, facility-vs-clinic flag, modifier, and effective date range, times units.
  2. custom SQL — Prices a drug charge for a United-associated customer by multiplying the national Medicare ASP drug fee by a United-specific specialty-group multiplier, where the specialty group is derived from a provider taxonomy crosswalk.
  3. custom SQL — Looks up a per-unit lab fee from United's 2021 lab fee schedule, keyed by a United specialty-group crosswalk, procedure code, and QW-modifier presence, then multiplies by units.
  4. custom SQL — Looks up a per-unit DME fee from United's 2021 DME fee schedule, keyed by a United specialty-group crosswalk, procedure code, and a single best-matching modifier (checked in a fixed priority order among RR/NU/UE/KM/KN/KF/AW/AU/AV), picking the highest-priority/highest-amount record; multiplies by units.
  5. custom SQL — Looks up a per-unit fee from United's 2021 RVU-based fee schedule, keyed by provider specialty group (from a United specialty crosswalk), facility-vs-clinic flag, procedure code, and modifier (26/TC/53), then multiplies by units.
  6. custom SQL — United general fee schedule: resolves specialty group and facility type, then looks up the matching rate from TransformUnitedFeeSchedule2021 by specialty group/facility-type/code/modifier (broader modifier set: 26,TC,KM,KN,NU,UE,RR), times Units.
  7. 40% of billed charges
Adjustments — all apply, in order
  1. multiple-procedure reduction (contract rules) — base codes 2 — when UnitedSpecialtyCategory A is present
  2. multiple-procedure reduction (contract rules) — base codes 2 — when UnitedSpecialtyCategory B is present
  3. multiple-procedure reduction (contract rules) — base codes 2 — when UnitedSpecialtyCategory C is present
  4. multiple-procedure reduction (contract rules) — base codes 2 — when UnitedSpecialtyCategory D is present
  5. multiple-procedure reduction (contract rules) — base codes 2 — when UnitedSpecialtyCategory E is present
  6. multiple-procedure reduction (contract rules) — base codes 2 — when UnitedSpecialtyCategory F is present
  7. multiple-procedure reduction (contract rules) — base codes 2 — when UnitedSpecialtyCategory G is present
  8. multiple-procedure reduction (contract rules) — base codes 2 — when UnitedSpecialtyCategory H is present
  9. cap each charge and the account total at 100% of billed charges
United-Healthcare-20226 base · 8 adj
United Healthcare
Profee · all facilities · 2022-03-01 → 2023-03-31
Base terms — first match wins
  1. custom SQL — Prices a charge from a United Healthcare 2021 'carveout' rate table, keyed by the billing provider's specialty group (resolved via a native schedule lookup), procedure code, facility-vs-clinic flag, modifier, and effective date range, times units.
  2. custom SQL — Prices a drug charge for a United-associated customer by multiplying the national Medicare ASP drug fee by a United-specific specialty-group multiplier, where the specialty group is derived from a provider taxonomy crosswalk.
  3. custom SQL — Looks up a per-unit lab fee from United's 2021 lab fee schedule, keyed by a United specialty-group crosswalk, procedure code, and QW-modifier presence, then multiplies by units.
  4. custom SQL — Looks up a per-unit DME fee from United's 2021 DME fee schedule, keyed by a United specialty-group crosswalk, procedure code, and a single best-matching modifier (checked in a fixed priority order among RR/NU/UE/KM/KN/KF/AW/AU/AV), picking the highest-priority/highest-amount record; multiplies by units.
  5. custom SQL — Looks up a per-unit fee from United's 2021 RVU-based fee schedule, keyed by provider specialty group (from a United specialty crosswalk), facility-vs-clinic flag, procedure code, and modifier (26/TC/53), then multiplies by units.
  6. 40% of billed charges
Adjustments — all apply, in order
  1. multiple-procedure reduction (contract rules) — base codes 2 — when UnitedSpecialtyCategory A is present
  2. multiple-procedure reduction (contract rules) — base codes 2 — when UnitedSpecialtyCategory B is present
  3. multiple-procedure reduction (contract rules) — base codes 2 — when UnitedSpecialtyCategory C is present
  4. multiple-procedure reduction (contract rules) — base codes 2 — when UnitedSpecialtyCategory D is present
  5. multiple-procedure reduction (contract rules) — base codes 2 — when UnitedSpecialtyCategory E is present
  6. multiple-procedure reduction (contract rules) — base codes 2 — when UnitedSpecialtyCategory F is present
  7. multiple-procedure reduction (contract rules) — base codes 2 — when UnitedSpecialtyCategory G is present
  8. multiple-procedure reduction (contract rules) — base codes 2 — when UnitedSpecialtyCategory H is present
United-Healthcare-20237 base · 16 adj
United Healthcare
Profee · all facilities · 2023-04-01 → 2099-12-31
Base terms — first match wins
  1. custom SQL — Prices a charge from a United Healthcare 2021 'carveout' rate table, keyed by the billing provider's specialty group (resolved via a native schedule lookup), procedure code, facility-vs-clinic flag, modifier, and effective date range, times units.
  2. custom SQL — United ASP drug fee: resolves specialty group and mid-level discount, looks up a specialty/code-specific multiplier from TransformUnitedASPMultiplier, and multiplies it by the national Medicare ASP drug base fee (via a CommonData table function) times Units.
  3. custom SQL — A United Healthcare lab fee: looks up a per-unit rate from United's 2021 lab fee schedule keyed by the provider's specialty group and procedure/modifier, multiplies by units, and applies a 5% discount if the provider is flagged mid-level.
  4. custom SQL — United DME fee: resolves the provider's United specialty group (via a taxonomy/specialty schedule) and a mid-level-provider discount flag, then looks up the top-priority United DME rate for that specialty group/code/modifier, applying a 0.95 multiplier for mid-level providers, times Units.
  5. custom SQL — United RVU-based fee: resolves specialty group and mid-level-provider discount, looks up the RVU-based rate from TransformUnitedRVU2021 by specialty group/facility-type/code/modifier (26/TC/53 priority), times Units, times the 0.95 mid-level discount if applicable.
  6. 40% of billed charges — when IsMidLevel Yes is present
  7. 40% of billed charges — when IsMidLevel Yes is absent
Adjustments — all apply, in order
  1. multiple-procedure reduction (contract rules) — base codes 2 — when UnitedSpecialtyCategory A is present
  2. multiple-procedure reduction (contract rules) — base codes 2 — when UnitedSpecialtyCategory B is present
  3. multiple-procedure reduction (contract rules) — base codes 2 — when UnitedSpecialtyCategory C is present
  4. multiple-procedure reduction (contract rules) — base codes 2 — when UnitedSpecialtyCategory D is present
  5. multiple-procedure reduction (contract rules) — base codes 2 — when UnitedSpecialtyCategory E is present
  6. multiple-procedure reduction (contract rules) — base codes 2 — when UnitedSpecialtyCategory F is present
  7. multiple-procedure reduction (contract rules) — base codes 2 — when UnitedSpecialtyCategory G is present
  8. multiple-procedure reduction (contract rules) — base codes 2 — when UnitedSpecialtyCategory H is present
  9. modifier 22 present → 135% of the running amount
  10. modifier 52 present → 90% of the running amount
  11. modifier 62 present → 62.5% 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 → 13.6% of the running amount
  16. modifier 78 present → 69% of the running amount
United-Healthcare-Medicare6 base · 13 adj
United Healthcare Medicare
Profee · all facilities · 2019-02-01 → 2099-12-31
Base terms — first match wins
  1. 100% of the Medicare-Drug fee schedule
  2. 100% of the Medicare-Lab fee schedule
  3. 100% of the Medicare-DME fee schedule
  4. 100% of the Medicare-RVU-Hospital/ASC fee schedule — when POS 11 is absent
  5. 100% of the Medicare-RVU-Clinic fee schedule — when POS 11 is present
  6. 40% of billed charges
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

Cannot fire (9)

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

Aetna · no contract map27 base · 4 adj
no contract map — cannot be resolved
Base terms — first match wins
  1. 100% of the Fixed-Fees-Orthopedic-PHYSI-Hospital fee schedule — when ProviderType Orthopedic PHYSICIAN SERVICES is present; POS 11 is absent
  2. 100% of the Fixed-Fees-Orthopedic-PHYSI-Clinic fee schedule — when ProviderType Orthopedic PHYSICIAN SERVICES is present; POS 11 is present
  3. 100% of the Fixed-Fees-DIAGNOSTIC-RADIO-Hospital fee schedule — when ProviderType Diagnostic Radiology is present; POS 11 is absent
  4. 100% of the Fixed-Fees-DIAGNOSTIC-RADIO-Clinic fee schedule — when ProviderType Diagnostic Radiology is present; POS 11 is present
  5. 100% of the Fixed-Fees-Urology-PHYSICIA-Hospital fee schedule — when ProviderType Urology PHYSICIAN SERVICES is present; POS 11 is absent
  6. 100% of the Fixed-Fees-Urology-PHYSICIA-Clinic fee schedule — when ProviderType Urology PHYSICIAN SERVICES is present; POS 11 is present
  7. 100% of the Fixed-Fees-PEDIATRIC-SUB-SP-Hospital fee schedule — when ProviderType MATERNAL FETAL MEDICINE PHYSICIAN SERVICES is present; POS 11 is absent
  8. 100% of the Fixed-Fees-PEDIATRIC-SUB-SP-Clinic fee schedule — when ProviderType PEDIATRIC SUB-SPECIALTIES, ENT, PATHOLOGY AND ENDOCRINOLOGY PHYSICIAN SERVICES is present; POS 11 is present
  9. 100% of the Fixed-Fees-MATERNAL-FETAL-M-Hospital fee schedule — when ProviderType MATERNAL FETAL MEDICINE PHYSICIAN SERVICES is present; POS 11 is absent
  10. 100% of the Fixed-Fees-MATERNAL-FETAL-M-Clinic fee schedule — when ProviderType MATERNAL FETAL MEDICINE PHYSICIAN SERVICES is present; POS 11 is present
  11. 100% of the Fixed-Fees-HEMO.ONC,-INFECT-Hospital fee schedule — when ProviderType HEMO.ONC, INFECTIOUS DISEASE, RADIATION ONCOLOGY DIETICIANS is present; POS 11 is absent
  12. 100% of the Fixed-Fees-HEMO.ONC,-INFECT-Clinic fee schedule — when ProviderType HEMO.ONC, INFECTIOUS DISEASE, RADIATION ONCOLOGY DIETICIANS is present; POS 11 is present
  13. 100% of the Fixed-Fees-PEDIATRIC-AND-AD-Hospital fee schedule — when ProviderType PEDIATRIC AND ADULT PRIMARY CARE PHYSICIAN SERVICES is present; POS 11 is absent
  14. 100% of the Fixed-Fees-PEDIATRIC-AND-AD-Clinic fee schedule — when ProviderType PEDIATRIC AND ADULT PRIMARY CARE PHYSICIAN SERVICES is present; POS 11 is present
  15. 100% of the Fixed-Fees-OB/GYN,-GYN-AND--Hospital fee schedule — when ProviderType OB/GYN, GYN AND REI/IVF PHYSICIAN is present; POS 11 is absent
  16. 100% of the Fixed-Fees-OB/GYN,-GYN-AND--Clinic fee schedule — when ProviderType OB/GYN, GYN AND REI/IVF PHYSICIAN is present; POS 11 is present
  17. 100% of the Fixed-Fees-GYN-ONC-PHYSICIA-Hospital fee schedule — when ProviderType GYN ONC PHYSICIAN AND Surgical Assistants is present; POS 11 is absent
  18. 100% of the Fixed-Fees-GYN-ONC-PHYSICIA-Clinic fee schedule — when ProviderType GYN ONC PHYSICIAN AND Surgical Assistants is present; POS 11 is present
  19. 100% of the Fixed-Fees-GENERAL-SURGERY--Hospital fee schedule — when ProviderType GENERAL SURGERY AND BREAST SURGEON SERVICES is present; POS 11 is absent
  20. 100% of the Fixed-Fees-GENERAL-SURGERY--Clinic fee schedule — when ProviderType GENERAL SURGERY AND BREAST SURGEON SERVICES is present; POS 11 is present
  21. 100% of the Fixed-Fees-COLON-RECTAL-PHY-Hospital fee schedule — when ProviderType COLON RECTAL PHYSICIAN SERVICES is present; POS 11 is absent
  22. 100% of the Fixed-Fees-COLON-RECTAL-PHY-Clinic fee schedule — when ProviderType COLON RECTAL PHYSICIAN SERVICES is present; POS 11 is present
  23. 100% of the Fixed-Fees-CARDIO,-DERM-AND-Hospital fee schedule — when ProviderType CARDIO, DERM AND ALLERGY PHYSICIAN SERVICES is present; POS 11 is absent
  24. 100% of the Fixed-Fees-CARDIO,-DERM-AND-Clinic fee schedule — when ProviderType CARDIO, DERM AND ALLERGY PHYSICIAN SERVICES is present; POS 11 is present
  25. 100% of the Fixed-Fees-DEFAULT-PHYSICIA-Hospital fee schedule — when POS 11 is absent; ProviderType DEFAULT PHYSICIAN SERVICES is present
  26. 100% of the Fixed-Fees-DEFAULT-PHYSICIA-Clinic fee schedule — when POS 11 is present; ProviderType DEFAULT PHYSICIAN SERVICES is present
  27. custom SQL — Flat 60% of billed charges, with no fee-schedule lookup at all.
Adjustments — all apply, in order
  1. multiple-procedure reduction (contract rules) — base codes 2, 3; pays 100/50%
  2. modifier 80 present → 16% of the running amount
  3. modifier Yes present → 85% of the running amount
  4. cap each charge and the account total at 100% of billed charges
AvMed-Diagnostic-Centers · no contract map11 base · 0 adj
no contract map — cannot be resolved
Base terms — first match wins
  1. 162% of the Fixed-Fees-Quaternary fee schedule
  2. 162% of the Fixed-Fees-Tertiary fee schedule
  3. 162% of the Fixed-Fees-Secondary fee schedule
  4. 162% of the Fixed-Fees-Hospital fee schedule — when POS 11 is absent
  5. 162% of the Fixed-Fees-Clinic fee schedule — when POS 11 is present
  6. 162% of the Medicare-Drug fee schedule
  7. 162% of the Medicare-Lab fee schedule
  8. 162% of the Medicare-DME fee schedule
  9. 162% of the Medicare-RVU-Hospital/ASC fee schedule — when POS 11 is absent
  10. 162% of the Medicare-RVU-Clinic fee schedule — when POS 11 is present
  11. 80% of billed charges
AvMed-Diagnostic-Centers-2021 · no contract map11 base · 0 adj
no contract map — cannot be resolved
Base terms — first match wins
  1. 168% of the Fixed-Fees-Quaternary fee schedule
  2. 168% of the Fixed-Fees-Tertiary fee schedule
  3. 168% of the Fixed-Fees-Secondary fee schedule
  4. 168% of the Fixed-Fees-Hospital fee schedule — when POS 11 is absent
  5. 168% of the Fixed-Fees-Clinic fee schedule — when POS 11 is present
  6. 168% of the Medicare-Drug fee schedule
  7. 168% of the Medicare-Lab fee schedule
  8. 168% of the Medicare-DME fee schedule
  9. 168% of the Medicare-RVU-Hospital/ASC fee schedule — when POS 11 is absent
  10. 168% of the Medicare-RVU-Clinic fee schedule — when POS 11 is present
  11. 80% of billed charges
AvMed-Diagnostic-Centers-2023 · no contract map11 base · 0 adj
no contract map — cannot be resolved
Base terms — first match wins
  1. 181% of the Fixed-Fees-Quaternary fee schedule
  2. 181% of the Fixed-Fees-Tertiary fee schedule
  3. 181% of the Fixed-Fees-Secondary fee schedule
  4. 181% of the Fixed-Fees-Hospital fee schedule — when POS 11 is absent
  5. 181% of the Fixed-Fees-Clinic fee schedule — when POS 11 is present
  6. 181% of the Medicare-Drug fee schedule
  7. 181% of the Medicare-Lab fee schedule
  8. 181% of the Medicare-DME fee schedule
  9. 181% of the Medicare-RVU-Hospital/ASC fee schedule — when POS 11 is absent
  10. 181% of the Medicare-RVU-Clinic fee schedule — when POS 11 is present
  11. 80% of billed charges
AvMed-Diagnostic-Centers-2024 · no contract map11 base · 0 adj
no contract map — cannot be resolved
Base terms — first match wins
  1. 191% of Medicare drug (rates as of 2009-01-01)
  2. 191% of Medicare lab (FL, rates as of 2009-01-01)
  3. 191% of Medicare DME (rates as of 2009-01-01)
  4. 191% of Medicare RVU (rates as of 2009-01-01) — when POS 11 is absent
  5. 191% of Medicare RVU (rates as of 2009-01-01) — when POS 11 is present
  6. 191% of Medicare drug
  7. 191% of Medicare lab
  8. 191% of Medicare DME
  9. 191% of Medicare RVU — when POS 11 is absent
  10. 191% of Medicare RVU — when POS 11 is present
  11. 80% of billed charges
AvMed-Medicare-Diagnostic-Centers · no contract map11 base · 0 adj
no contract map — cannot be resolved
Base terms — first match wins
  1. 100% of the Fixed-Fees-Quaternary fee schedule
  2. 100% of the Fixed-Fees-Tertiary fee schedule
  3. 100% of the Fixed-Fees-Secondary fee schedule
  4. 100% of the Fixed-Fees-Hospital fee schedule — when POS 11 is absent
  5. 100% of the Fixed-Fees-Clinic fee schedule — when POS 11 is present
  6. 100% of the Medicare-Drug fee schedule
  7. 100% of the Medicare-Lab fee schedule
  8. 100% of the Medicare-DME fee schedule
  9. 100% of the Medicare-RVU-Hospital/ASC fee schedule — when POS 11 is absent
  10. 100% of the Medicare-RVU-Clinic fee schedule — when POS 11 is present
  11. 80% of billed charges
BCBS-FL-Profee-Diagnostic-Centers · no contract map7 base · 0 adj
no contract map — cannot be resolved
Base terms — first match wins
  1. 100% of the Fixed-Fees-Clinic fee schedule — when BCBSSpecialtyCategory 16 is present; POS 11 is present ⚠︎ named “131% of 2010 Medicare Clinic Allowable” but configured at 100%
  2. 100% of the Fixed-Fees-Hospital fee schedule — when BCBSSpecialtyCategory 16 is present; POS 21 is present ⚠︎ named “131% of 2010 Medicare Hospital Allowable” but configured at 100%
  3. 100% of the Medicare-Lab fee schedule — when BCBSSpecialtyCategory 16 is present
  4. 100% of the Medicare-Drug fee schedule — when BCBSSpecialtyCategory 16 is present
  5. 100% of the Medicare-DME fee schedule — when BCBSSpecialtyCategory 16 is present
  6. 100% of the Medicare-RVU-Clinic fee schedule — when POS 11 is present; BCBSSpecialtyCategory 16 is present
  7. 100% of the Medicare-RVU-Hospital/ASC fee schedule — when POS 21 is present; BCBSSpecialtyCategory 16 is present
Chargelogic-Profee · no contract map1 base · 0 adj
no contract map — cannot be resolved
Base terms — first match wins
  1. custom SQL — Hospital chargemaster (list) price for a procedure/modifier as of the service date -- the raw self-pay/undiscounted charge rate, not a negotiated payer rate.
Sunshine-With-Diagnostic · no contract map9 base · 1 adj
no contract map — cannot be resolved
Base terms — first match wins
  1. 100% of the Fixed-Fees fee schedule
  2. custom SQL — Prices a drug charge for a Sunshine Health-associated customer by taking the Medicare fee-schedule drug amount and multiplying it by a provider-specialty-specific rate multiplier resolved through the customer's Sunshine specialty crosswalk.
  3. custom SQL — A Medicare DME fee for Sunshine Health, scaled by a specialty-specific rate multiplier -- same shape as the RVU and Drug variants (07aba51389aa16d8, ec42d15138c5a93b) but sourced from the Medicare-DME fee schedule.
  4. custom SQL — Prices a lab charge off the Medicare clinical-lab fee schedule for the given facility/date/procedure/modifier, then rescales it by a provider-specialty-specific rate multiplier from a customer 'Sunshine' incentive-program table, keyed by the provider's specialty (resolved via a customer specialty crosswalk).
  5. custom SQL — A Medicare-RVU-based fee for Sunshine Health, scaled by a specialty-specific rate multiplier: looks up the RVU dollar amount from the customer's own Medicare-RVU fee schedule, then multiplies by a per-specialty 'Rate' pulled from a Sunshine-specific transform table.
  6. 40% of billed charges — when SunshineSpecialtyCategory 4 is present
  7. 40% of billed charges — when SunshineSpecialtyCategory 3 is present
  8. 40% of billed charges — when SunshineSpecialtyCategory 2 is present
  9. 40% of billed charges — when SunshineSpecialtyCategory 1 is present
Adjustments — all apply, in order
  1. cap each charge and the account total at 100% of billed charges