Customer detail

HeatonEye

34
live contracts
6
cannot fire
21
calc types
3
SQL bodies
1
of those blocked
0
map conflicts

Methodology mix

ModifierAdjustment486
PercentOfFees41
LesserOfAdjustment37
MedicareMultipleRadiologyAdjustment35
MidLevelProviderAdjustment28
MedicareMultipleEndoscopyAdjustment28
MedicareMultipleProcedureAdjustment28
SqlExpression18
MedicareRVU17
FlatPercentOfCharges16
MedicareLab13
MedicareDrug13
MedicareDME13
MedicareASC10
MultipleEndoscopyAdjustment9
MultipleRadiologyAdjustment9
PercentageAdjustment9
MultipleProcedureAdjustment9
PercentOfCharges5
FlatFee1
MedicareMultipleSurgeryAdjustment1

Contracts

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

Aetna13 base · 18 adj
Aetna
Profee · Clinic · 2023-01-01 → 2999-12-31
Base terms — first match wins
  1. custom SQL — Zeroes the allowed amount for two specific drug HCPCS codes (J1097, J1096) — an unconditional 'no separate payment' exclusion for those two codes.
  2. 100% of the AetnaCarveOuts fee schedule
  3. 135% of Medicare RVU — when CPTCategories-Aetna Evaluation and Management is present
  4. 125% of the Aetna-Profee-Fees fee schedule — when CPTCategories-Aetna Drugs is present
  5. 125% of the Aetna-Profee-Fees fee schedule — when CPTCategories-Aetna Medicine is present
  6. 125% of the Aetna-Profee-Fees fee schedule — when CPTCategories-Aetna Immunizations is present
  7. 125% of the Aetna-Profee-Fees fee schedule — when CPTCategories-Aetna Laboratory is present
  8. 125% of the Aetna-Profee-Fees fee schedule — when CPTCategories-Aetna Radiology is present
  9. 150% of Medicare lab
  10. 150% of Medicare drug
  11. 150% of Medicare DME
  12. 150% of Medicare RVU
  13. 0% of billed charges — when PropertyTypeRule in NC
Adjustments — all apply, in order
  1. multiple-procedure reduction (contract rules) — base codes 2, 3; pays 100/50%
  2. multiple-endoscopy reduction (contract rules)
  3. multiple-radiology reduction (contract rules) — base codes 4
  4. rescale by a percentage read from the Mid-Level-Provider schedule
  5. modifier 22 present → 135% of the running amount
  6. modifier 50 present → 150% of the running amount
  7. modifier 52 present → 50% of the running amount
  8. modifier 54 present → 80% of the running amount
  9. modifier 62 present → 62.5% of the running amount
  10. modifier 78 present → 70% of the running amount
  11. modifier 80 present → 16% of the running amount
  12. modifier 81 present → 16% of the running amount
  13. modifier 82 present → 16% of the running amount
  14. modifier AS present → 14% of the running amount
  15. modifier QY present → 50% of the running amount
  16. modifier QK present → 50% of the running amount
  17. modifier QX present → 50% of the running amount
  18. cap each charge and the account total at 100% of billed charges
Aetna Medicare5 base · 18 adj
Aetna Medicare
Profee · all facilities · 2023-01-01 → 2024-03-31
Base terms — first match wins
  1. 0% of billed charges — when NonCovered NC is present
  2. 100% of Medicare lab (rates as of 2023-04-01)
  3. 100% of Medicare drug (rates as of 2023-04-01)
  4. 100% of Medicare DME (rates as of 2023-04-01)
  5. 100% of Medicare RVU (rates as of 2023-04-01)
Adjustments — all apply, in order
  1. multiple-procedure reduction (contract rules) — base codes 2, 3; pays 100/50%
  2. multiple-endoscopy reduction (contract rules)
  3. multiple-radiology reduction (contract rules) — base codes 4
  4. rescale by a percentage read from the Mid-Level-Provider schedule
  5. modifier 22 present → 135% of the running amount
  6. modifier 50 present → 150% of the running amount
  7. modifier 52 present → 50% of the running amount
  8. modifier 54 present → 80% of the running amount
  9. modifier 62 present → 62.5% of the running amount
  10. modifier 78 present → 70% of the running amount
  11. modifier 80 present → 16% of the running amount
  12. modifier 81 present → 16% of the running amount
  13. modifier 82 present → 16% of the running amount
  14. modifier AS present → 14% of the running amount
  15. modifier QY present → 50% of the running amount
  16. modifier QK present → 50% of the running amount
  17. modifier QX present → 50% of the running amount
  18. cap each charge and the account total at 100% of billed charges
Aetna Medicare 2024 5 base · 18 adj
Aetna Medicare
Profee · all facilities · 2024-04-01 → 2025-03-31
Base terms — first match wins
  1. 0% of billed charges — when NonCovered NC is present
  2. 100% of Medicare lab (rates as of 2024-04-01)
  3. 100% of Medicare drug (rates as of 2024-04-01)
  4. 100% of Medicare DME (rates as of 2024-04-01)
  5. 100% of Medicare RVU (rates as of 2024-04-01)
Adjustments — all apply, in order
  1. multiple-procedure reduction (contract rules) — base codes 2, 3; pays 100/50%
  2. multiple-endoscopy reduction (contract rules)
  3. multiple-radiology reduction (contract rules) — base codes 4
  4. rescale by a percentage read from the Mid-Level-Provider schedule
  5. modifier 22 present → 135% of the running amount
  6. modifier 50 present → 150% of the running amount
  7. modifier 52 present → 50% of the running amount
  8. modifier 54 present → 80% of the running amount
  9. modifier 62 present → 62.5% of the running amount
  10. modifier 78 present → 70% of the running amount
  11. modifier 80 present → 16% of the running amount
  12. modifier 81 present → 16% of the running amount
  13. modifier 82 present → 16% of the running amount
  14. modifier AS present → 14% of the running amount
  15. modifier QY present → 50% of the running amount
  16. modifier QK present → 50% of the running amount
  17. modifier QX present → 50% of the running amount
  18. cap each charge and the account total at 100% of billed charges
Aetna Medicare 20255 base · 18 adj
Aetna Medicare
Profee · all facilities · 2025-04-01 → 2026-03-31
Base terms — first match wins
  1. 0% of billed charges — when NonCovered NC is present
  2. 100% of Medicare lab (rates as of 2025-04-01)
  3. 100% of Medicare drug (rates as of 2025-04-01)
  4. 100% of Medicare DME (rates as of 2025-04-01)
  5. 100% of Medicare RVU (rates as of 2025-04-01)
Adjustments — all apply, in order
  1. multiple-procedure reduction (contract rules) — base codes 2, 3; pays 100/50%
  2. multiple-endoscopy reduction (contract rules)
  3. multiple-radiology reduction (contract rules) — base codes 4
  4. rescale by a percentage read from the Mid-Level-Provider schedule
  5. modifier 22 present → 135% of the running amount
  6. modifier 50 present → 150% of the running amount
  7. modifier 52 present → 50% of the running amount
  8. modifier 54 present → 80% of the running amount
  9. modifier 62 present → 62.5% of the running amount
  10. modifier 78 present → 70% of the running amount
  11. modifier 80 present → 16% of the running amount
  12. modifier 81 present → 16% of the running amount
  13. modifier 82 present → 16% of the running amount
  14. modifier AS present → 14% of the running amount
  15. modifier QY present → 50% of the running amount
  16. modifier QK present → 50% of the running amount
  17. modifier QX present → 50% of the running amount
  18. cap each charge and the account total at 100% of billed charges
Aetna Medicare 20265 base · 18 adj
Aetna Medicare
Profee · all facilities · 2026-04-01 → 2027-03-31
Base terms — first match wins
  1. 0% of billed charges — when NonCovered NC is present
  2. 100% of Medicare lab (rates as of 2026-04-01)
  3. 100% of Medicare drug (rates as of 2026-04-01)
  4. 100% of Medicare DME (rates as of 2026-04-01)
  5. 100% of Medicare RVU (rates as of 2026-04-01)
Adjustments — all apply, in order
  1. multiple-procedure reduction (contract rules) — base codes 2, 3; pays 100/50%
  2. multiple-endoscopy reduction (contract rules)
  3. multiple-radiology reduction (contract rules) — base codes 4
  4. rescale by a percentage read from the Mid-Level-Provider schedule
  5. modifier 22 present → 135% of the running amount
  6. modifier 50 present → 150% of the running amount
  7. modifier 52 present → 50% of the running amount
  8. modifier 54 present → 80% of the running amount
  9. modifier 62 present → 62.5% of the running amount
  10. modifier 78 present → 70% of the running amount
  11. modifier 80 present → 16% of the running amount
  12. modifier 81 present → 16% of the running amount
  13. modifier 82 present → 16% of the running amount
  14. modifier AS present → 14% of the running amount
  15. modifier QY present → 50% of the running amount
  16. modifier QK present → 50% of the running amount
  17. modifier QX present → 50% of the running amount
  18. cap each charge and the account total at 100% of billed charges
Aetna-Facility2 base · 18 adj
Aetna
Facility · ASC, Hospital · 2024-01-01 → 2999-12-31
Base terms — first match wins
  1. custom SQL — Zeroes the allowed amount for two specific drug HCPCS codes (J1097, J1096) — an unconditional 'no separate payment' exclusion for those two codes.
  2. 100% of the Facility-Fees fee schedule
Adjustments — all apply, in order
  1. multiple-procedure reduction (contract rules) — base codes 2, 3; pays 100/50%
  2. multiple-endoscopy reduction (contract rules)
  3. multiple-radiology reduction (contract rules) — base codes 4
  4. rescale by a percentage read from the Mid-Level-Provider schedule
  5. modifier 22 present → 135% of the running amount
  6. modifier 50 present → 150% of the running amount
  7. modifier 52 present → 50% of the running amount
  8. modifier 54 present → 80% of the running amount
  9. modifier 62 present → 62.5% of the running amount
  10. modifier 78 present → 70% of the running amount
  11. modifier 80 present → 16% of the running amount
  12. modifier 81 present → 16% of the running amount
  13. modifier 82 present → 16% of the running amount
  14. modifier AS present → 14% of the running amount
  15. modifier QY present → 50% of the running amount
  16. modifier QK present → 50% of the running amount
  17. modifier QX present → 50% of the running amount
  18. cap each charge and the account total at 100% of billed charges
Aetna-Medicare-ASC1 base · 18 adj
Aetna Medicare
Facility · all facilities · 2023-01-01 → 2999-12-31
Base terms — first match wins
  1. 100% of Medicare ASC
Adjustments — all apply, in order
  1. Medicare multiple-procedure reduction — base codes 2, 3; pays 100/50%
  2. Medicare multiple-endoscopy reduction
  3. Medicare multiple-radiology reduction — base codes 4
  4. mid-level provider reduction (by NUCC taxonomy)
  5. modifier 22 present → 135% of the running amount
  6. modifier 50 present → 150% of the running amount
  7. modifier 52 present → 50% of the running amount
  8. modifier 54 present → 80% of the running amount
  9. modifier 62 present → 62.5% of the running amount
  10. modifier 78 present → 70% of the running amount
  11. modifier 80 present → 16% of the running amount
  12. modifier 81 present → 16% of the running amount
  13. modifier 82 present → 16% of the running amount
  14. modifier AS present → 14% of the running amount
  15. modifier QY present → 50% of the running amount
  16. modifier QK present → 50% of the running amount
  17. modifier QX present → 50% of the running amount
  18. cap each charge and the account total at 100% of billed charges
Aetna-Profee-Facility13 base · 18 adj
Aetna
Profee · ASC, Hospital · 2023-01-01 → 2999-12-31
Base terms — first match wins
  1. custom SQL — Zeroes the allowed amount for two specific drug HCPCS codes (J1097, J1096) — an unconditional 'no separate payment' exclusion for those two codes.
  2. 100% of the AetnaCarveOuts fee schedule
  3. 130% of Medicare RVU — when CPTCategories-Aetna Evaluation and Management is present
  4. 100% of the Aetna-Facility-Profee-Fees fee schedule — when CPTCategories-Aetna Drugs is present ⚠︎ named “125% Aetna Market Fee Schedule - Drugs” but configured at 100%
  5. 100% of the Aetna-Facility-Profee-Fees fee schedule — when CPTCategories-Aetna Medicine is present ⚠︎ named “125% Aetna Market Fee Schedule - Medicine” but configured at 100%
  6. 100% of the Aetna-Facility-Profee-Fees fee schedule — when CPTCategories-Aetna Immunizations is present ⚠︎ named “125% Aetna Market Fee Schedule - Immunizations” but configured at 100%
  7. 100% of the Aetna-Facility-Profee-Fees fee schedule — when CPTCategories-Aetna Laboratory is present ⚠︎ named “125% Aetna Market Fee Schedule - Laboratory” but configured at 100%
  8. 100% of the Aetna-Facility-Profee-Fees fee schedule — when CPTCategories-Aetna Radiology is present ⚠︎ named “125% Aetna Market Fee Schedule - Radiology” but configured at 100%
  9. 150% of Medicare lab
  10. 150% of Medicare drug
  11. 150% of Medicare DME
  12. 150% of Medicare RVU
  13. 0% of billed charges — when PropertyTypeRule in NC
Adjustments — all apply, in order
  1. Medicare multiple-procedure reduction — base codes 2, 3; pays 100/50%
  2. Medicare multiple-endoscopy reduction
  3. Medicare multiple-radiology reduction — base codes 4
  4. mid-level provider reduction (by NUCC taxonomy)
  5. modifier 22 present → 135% of the running amount
  6. modifier 50 present → 150% of the running amount
  7. modifier 52 present → 50% of the running amount
  8. modifier 54 present → 80% of the running amount
  9. modifier 62 present → 62.5% of the running amount
  10. modifier 78 present → 70% of the running amount
  11. modifier 80 present → 16% of the running amount
  12. modifier 81 present → 16% of the running amount
  13. modifier 82 present → 16% of the running amount
  14. modifier AS present → 14% of the running amount
  15. modifier QY present → 50% of the running amount
  16. modifier QK present → 50% of the running amount
  17. modifier QX present → 50% of the running amount
  18. cap each charge and the account total at 100% of billed charges
BCBS3 base · 19 adj
BCBS, BCBS-BlueChoice, BCBS-BlueEssentials
Profee · Clinic · 2023-01-01 → 2024-01-31
Base terms — first match wins
  1. custom SQL — Zeroes the allowed amount for two specific drug HCPCS codes (J1097, J1096) — an unconditional 'no separate payment' exclusion for those two codes.
  2. 100% of the Profee-Fees fee schedule
  3. 0% of billed charges — when NonCovered NC is present
Adjustments — all apply, in order
  1. Medicare multiple-procedure reduction — base codes 2, 3; pays 100/50%
  2. Medicare multiple-radiology reduction — base codes 7
  3. Medicare multiple-endoscopy reduction
  4. Medicare multiple-radiology reduction — base codes 4
  5. mid-level provider reduction (by NUCC taxonomy)
  6. modifier 22 present → 135% of the running amount
  7. modifier 50 present → 150% of the running amount
  8. modifier 52 present → 50% of the running amount
  9. modifier 54 present → 80% of the running amount
  10. modifier 62 present → 62.5% of the running amount
  11. modifier 78 present → 70% of the running amount
  12. modifier 80 present → 16% of the running amount
  13. modifier 81 present → 16% of the running amount
  14. modifier 82 present → 16% of the running amount
  15. modifier AS present → 14% of the running amount
  16. modifier QY present → 50% of the running amount
  17. modifier QK present → 50% of the running amount
  18. modifier QX present → 50% of the running amount
  19. cap each charge and the account total at 100% of billed charges
BCBS MD/OD Fee Schedule Profees6 base · 19 adj
BCBS, BCBS-BlueChoice, BCBS-BlueEssentials
Profee · all facilities · 2024-02-01 → 2999-12-31
Base terms — first match wins
  1. custom SQL — Zeroes the allowed amount for two specific drug HCPCS codes (J1097, J1096) — an unconditional 'no separate payment' exclusion for those two codes.
  2. 100% of the Profee-Fees-OD fee schedule — when ProviderDegree OD is present
  3. percent-of-charges, rate read from the OD-PercentOfCharge-Profees schedule — when ProviderDegree OD is present
  4. 100% of the Profee-Fees-MD fee schedule
  5. percent-of-charges, rate read from the MD-PercentOfCharge-Profees schedule
  6. 0% of billed charges — when PropertyTypeRule in NC
Adjustments — all apply, in order
  1. Medicare multiple-procedure reduction — base codes 2, 3; pays 100/50%
  2. Medicare multiple-radiology reduction — base codes 7
  3. Medicare multiple-radiology reduction — base codes 4
  4. Medicare multiple-endoscopy reduction
  5. mid-level provider reduction (by NUCC taxonomy)
  6. modifier 22 present → 135% of the running amount
  7. modifier 50 present → 150% of the running amount
  8. modifier 52 present → 50% of the running amount
  9. modifier 54 present → 80% of the running amount
  10. modifier 62 present → 62.5% of the running amount
  11. modifier 78 present → 70% of the running amount
  12. modifier 80 present → 16% of the running amount
  13. modifier 81 present → 16% of the running amount
  14. modifier 82 present → 16% of the running amount
  15. modifier AS present → 14% of the running amount
  16. modifier QY present → 50% of the running amount
  17. modifier QK present → 50% of the running amount
  18. modifier QX present → 50% of the running amount
  19. cap each charge and the account total at 100% of billed charges
BCBS-ASC4 base · 18 adj
BCBS, BCBS-BlueChoice, BCBS-BlueEssentials
Facility · ASC, Hospital · 2023-01-01 → 2023-12-31
Base terms — first match wins
  1. custom SQL — Zeroes the allowed amount for two specific drug HCPCS codes (J1097, J1096) — an unconditional 'no separate payment' exclusion for those two codes.
  2. 100% of the Carveouts fee schedule
  3. 100% of the Facility-Fees fee schedule
  4. 100% of the NonCoveredServices fee schedule
Adjustments — all apply, in order
  1. Medicare multiple-procedure reduction — base codes 2, 3; pays 100/50%
  2. Medicare multiple-endoscopy reduction
  3. Medicare multiple-radiology reduction — base codes 4
  4. mid-level provider reduction (by NUCC taxonomy)
  5. modifier 22 present → 135% of the running amount
  6. modifier 50 present → 150% of the running amount
  7. modifier 52 present → 50% of the running amount
  8. modifier 54 present → 80% of the running amount
  9. modifier 62 present → 62.5% of the running amount
  10. modifier 78 present → 70% of the running amount
  11. modifier 80 present → 16% of the running amount
  12. modifier 81 present → 16% of the running amount
  13. modifier 82 present → 16% of the running amount
  14. modifier AS present → 14% of the running amount
  15. modifier QY present → 50% of the running amount
  16. modifier QK present → 50% of the running amount
  17. modifier QX present → 50% of the running amount
  18. cap each charge and the account total at 100% of billed charges
BCBS-Facility-Fees4 base · 19 adj
BCBS, BCBS-BlueChoice, BCBS-BlueEssentials
Facility · all facilities · 2024-01-01 → 2999-12-31
Base terms — first match wins
  1. flat $0 — when ProcedureCode 68841 is present
  2. custom SQL — Zeroes the allowed amount for two specific drug HCPCS codes (J1097, J1096) — an unconditional 'no separate payment' exclusion for those two codes.
  3. 100% of the Facility-Fees fee schedule
  4. 100% of the NonCoveredServices fee schedule
Adjustments — all apply, in order
  1. Medicare multiple-procedure reduction — base codes 2, 3; pays 100/50%
  2. Medicare multiple-surgery reduction — pays 100/50%
  3. Medicare multiple-endoscopy reduction
  4. Medicare multiple-radiology reduction — base codes 4
  5. mid-level provider reduction (by NUCC taxonomy)
  6. modifier 22 present → 135% of the running amount
  7. modifier 50 present → 150% of the running amount
  8. modifier 52 present → 50% of the running amount
  9. modifier 54 present → 80% of the running amount
  10. modifier 62 present → 62.5% of the running amount
  11. modifier 78 present → 70% of the running amount
  12. modifier 80 present → 16% of the running amount
  13. modifier 81 present → 16% of the running amount
  14. modifier 82 present → 16% of the running amount
  15. modifier AS present → 14% of the running amount
  16. modifier QY present → 50% of the running amount
  17. modifier QK present → 50% of the running amount
  18. modifier QX present → 50% of the running amount
  19. cap each charge and the account total at 100% of billed charges
BCBS-Facility-Profees3 base · 18 adj
BCBS, BCBS-BlueChoice, BCBS-BlueEssentials
Profee · ASC, Hospital · 2023-01-01 → 2024-01-31
Base terms — first match wins
  1. custom SQL — Zeroes the allowed amount for two specific drug HCPCS codes (J1097, J1096) — an unconditional 'no separate payment' exclusion for those two codes.
  2. 0% of the NonCoveredServices fee schedule — when NonCovered NC is present
  3. 100% of the Profee-Fees fee schedule
Adjustments — all apply, in order
  1. Medicare multiple-procedure reduction — base codes 2, 3; pays 100/50%
  2. Medicare multiple-endoscopy reduction
  3. Medicare multiple-radiology reduction — base codes 4
  4. mid-level provider reduction (by NUCC taxonomy)
  5. modifier 22 present → 135% of the running amount
  6. modifier 50 present → 150% of the running amount
  7. modifier 52 present → 50% of the running amount
  8. modifier 54 present → 80% of the running amount
  9. modifier 62 present → 62.5% of the running amount
  10. modifier 78 present → 70% of the running amount
  11. modifier 80 present → 16% of the running amount
  12. modifier 81 present → 16% of the running amount
  13. modifier 82 present → 16% of the running amount
  14. modifier AS present → 14% of the running amount
  15. modifier QY present → 50% of the running amount
  16. modifier QK present → 50% of the running amount
  17. modifier QX present → 50% of the running amount
  18. cap each charge and the account total at 100% of billed charges
BCBS-Medicare-ASC1 base · 18 adj
BCBS Medicare Advantage
Facility · ASC, Hospital · 2023-01-01 → 2999-12-31
Base terms — first match wins
  1. 100% of Medicare ASC
Adjustments — all apply, in order
  1. Medicare multiple-procedure reduction — base codes 2, 3; pays 100/50%
  2. Medicare multiple-endoscopy reduction
  3. Medicare multiple-radiology reduction — base codes 4
  4. mid-level provider reduction (by NUCC taxonomy)
  5. modifier 22 present → 135% of the running amount
  6. modifier 50 present → 150% of the running amount
  7. modifier 52 present → 50% of the running amount
  8. modifier 54 present → 80% of the running amount
  9. modifier 62 present → 62.5% of the running amount
  10. modifier 78 present → 70% of the running amount
  11. modifier 80 present → 16% of the running amount
  12. modifier 81 present → 16% of the running amount
  13. modifier 82 present → 16% of the running amount
  14. modifier AS present → 14% of the running amount
  15. modifier QY present → 50% of the running amount
  16. modifier QK present → 50% of the running amount
  17. modifier QX present → 50% of the running amount
  18. cap each charge and the account total at 100% of billed charges
Charges-Facility1 base · 0 adj
Charges
Facility · all facilities · 2023-01-01 → 2999-12-31
Base terms — first match wins
  1. 100% of the ChargeMaster-ASC fee schedule
Charges-Profee1 base · 0 adj
Charges
Profee · all facilities · 2023-01-01 → 2999-12-31
Base terms — first match wins
  1. 100% of the ChargeMaster-Profee fee schedule
Cigna-Commercial4 base · 18 adj
Cigna Commercial
Profee · all facilities · 2023-03-15 → 2999-12-31
Base terms — first match wins
  1. custom SQL — Zeroes the allowed amount for two specific drug HCPCS codes (J1097, J1096) — an unconditional 'no separate payment' exclusion for those two codes.
  2. percent-of-charges, rate read from the Percent-Of-Charges schedule
  3. 100% of the Profee-Fees fee schedule
  4. 50% of billed charges
Adjustments — all apply, in order
  1. Medicare multiple-procedure reduction — base codes 2, 3; pays 100/50%
  2. Medicare multiple-endoscopy reduction
  3. Medicare multiple-radiology reduction — base codes 4
  4. mid-level provider reduction (by NUCC taxonomy)
  5. modifier 22 present → 135% of the running amount
  6. modifier 50 present → 150% of the running amount
  7. modifier 52 present → 50% of the running amount
  8. modifier 54 present → 80% of the running amount
  9. modifier 62 present → 62.5% of the running amount
  10. modifier 78 present → 70% of the running amount
  11. modifier 80 present → 16% of the running amount
  12. modifier 81 present → 16% of the running amount
  13. modifier 82 present → 16% of the running amount
  14. modifier AS present → 14% of the running amount
  15. modifier QY present → 50% of the running amount
  16. modifier QK present → 50% of the running amount
  17. modifier QX present → 50% of the running amount
  18. cap each charge and the account total at 100% of billed charges
Cigna-Facility3 base · 18 adj
Cigna Commercial
Facility · ASC, Hospital · 2024-01-01 → 2999-12-31
Base terms — first match wins
  1. custom SQL — Zeroes the allowed amount for two specific drug HCPCS codes (J1097, J1096) — an unconditional 'no separate payment' exclusion for those two codes.
  2. 100% of the Facility-Fees fee schedule
  3. percent-of-charges, rate read from the Percent-Of-Charges-Facility schedule
Adjustments — all apply, in order
  1. Medicare multiple-procedure reduction — base codes 2, 3; pays 100/50%
  2. Medicare multiple-endoscopy reduction
  3. Medicare multiple-radiology reduction — base codes 4
  4. mid-level provider reduction (by NUCC taxonomy)
  5. modifier 22 present → 135% of the running amount
  6. modifier 50 present → 150% of the running amount
  7. modifier 52 present → 50% of the running amount
  8. modifier 54 present → 80% of the running amount
  9. modifier 62 present → 62.5% of the running amount
  10. modifier 78 present → 70% of the running amount
  11. modifier 80 present → 16% of the running amount
  12. modifier 81 present → 16% of the running amount
  13. modifier 82 present → 16% of the running amount
  14. modifier AS present → 14% of the running amount
  15. modifier QY present → 50% of the running amount
  16. modifier QK present → 50% of the running amount
  17. modifier QX present → 50% of the running amount
  18. cap each charge and the account total at 100% of billed charges
Cigna-Medicare5 base · 19 adj
Cigna Medicare
Profee · all facilities · 2023-01-01 → 2999-12-31
Base terms — first match wins
  1. 0% of billed charges — when NonCovered NC is present
  2. 100% of Medicare lab
  3. 100% of Medicare drug
  4. 100% of Medicare DME
  5. 100% of Medicare RVU
Adjustments — all apply, in order
  1. Medicare multiple-procedure reduction — base codes 2, 3; pays 100/50%
  2. Medicare multiple-radiology reduction — base codes 7
  3. Medicare multiple-endoscopy reduction
  4. Medicare multiple-radiology reduction — base codes 4
  5. mid-level provider reduction (by NUCC taxonomy)
  6. modifier 22 present → 135% of the running amount
  7. modifier 50 present → 150% of the running amount
  8. modifier 52 present → 50% of the running amount
  9. modifier 54 present → 80% of the running amount
  10. modifier 62 present → 62.5% of the running amount
  11. modifier 78 present → 70% of the running amount
  12. modifier 80 present → 16% of the running amount
  13. modifier 81 present → 16% of the running amount
  14. modifier 82 present → 16% of the running amount
  15. modifier AS present → 14% of the running amount
  16. modifier QY present → 50% of the running amount
  17. modifier QK present → 50% of the running amount
  18. modifier QX present → 50% of the running amount
  19. cap each charge and the account total at 100% of billed charges
Cigna-Medicare-ASC1 base · 18 adj
Cigna Medicare
Facility · all facilities · 2023-01-01 → 2999-12-31
Base terms — first match wins
  1. 100% of Medicare ASC
Adjustments — all apply, in order
  1. Medicare multiple-procedure reduction — base codes 2, 3; pays 100/50%
  2. Medicare multiple-endoscopy reduction
  3. Medicare multiple-radiology reduction
  4. mid-level provider reduction (by NUCC taxonomy)
  5. modifier 22 present → 135% of the running amount
  6. modifier 50 present → 150% of the running amount
  7. modifier 52 present → 50% of the running amount
  8. modifier 54 present → 80% of the running amount
  9. modifier 62 present → 62.5% of the running amount
  10. modifier 78 present → 70% of the running amount
  11. modifier 80 present → 16% of the running amount
  12. modifier 81 present → 16% of the running amount
  13. modifier 82 present → 16% of the running amount
  14. modifier AS present → 14% of the running amount
  15. modifier QY present → 50% of the running amount
  16. modifier QK present → 50% of the running amount
  17. modifier QX present → 50% of the running amount
  18. cap each charge and the account total at 100% of billed charges
Humana6 base · 18 adj
Humana
Profee · all facilities · 2023-01-01 → 2999-12-31
Base terms — first match wins
  1. custom SQL — Zeroes the allowed amount for two specific drug HCPCS codes (J1097, J1096) — an unconditional 'no separate payment' exclusion for those two codes.
  2. 180% of Medicare lab
  3. 180% of Medicare drug
  4. 180% of Medicare DME
  5. 150% of Medicare RVU — when CPTCategories Evaluation & Management is present
  6. 180% of Medicare RVU
Adjustments — all apply, in order
  1. Medicare multiple-procedure reduction — base codes 2, 3; pays 100/50%
  2. Medicare multiple-endoscopy reduction
  3. Medicare multiple-radiology reduction — base codes 4
  4. mid-level provider reduction (by NUCC taxonomy)
  5. modifier 22 present → 135% of the running amount
  6. modifier 50 present → 150% of the running amount
  7. modifier 52 present → 50% of the running amount
  8. modifier 54 present → 80% of the running amount
  9. modifier 62 present → 62.5% of the running amount
  10. modifier 78 present → 70% of the running amount
  11. modifier 80 present → 16% of the running amount
  12. modifier 81 present → 16% of the running amount
  13. modifier 82 present → 16% of the running amount
  14. modifier AS present → 14% of the running amount
  15. modifier QY present → 50% of the running amount
  16. modifier QK present → 50% of the running amount
  17. modifier QX present → 50% of the running amount
  18. cap each charge and the account total at 100% of billed charges
Humana-Facility-Fees2 base · 18 adj
Humana
Facility · all facilities · 2023-01-01 → 2999-12-31
Base terms — first match wins
  1. custom SQL — Zeroes the allowed amount for two specific drug HCPCS codes (J1097, J1096) — an unconditional 'no separate payment' exclusion for those two codes.
  2. 100% of the Facility-Fees fee schedule
Adjustments — all apply, in order
  1. Medicare multiple-procedure reduction — base codes 2, 3; pays 100/50%
  2. Medicare multiple-endoscopy reduction
  3. Medicare multiple-radiology reduction — base codes 4
  4. mid-level provider reduction (by NUCC taxonomy)
  5. modifier 22 present → 135% of the running amount
  6. modifier 50 present → 150% of the running amount
  7. modifier 52 present → 50% of the running amount
  8. modifier 54 present → 80% of the running amount
  9. modifier 62 present → 62.5% of the running amount
  10. modifier 78 present → 70% of the running amount
  11. modifier 80 present → 16% of the running amount
  12. modifier 81 present → 16% of the running amount
  13. modifier 82 present → 16% of the running amount
  14. modifier AS present → 14% of the running amount
  15. modifier QY present → 50% of the running amount
  16. modifier QK present → 50% of the running amount
  17. modifier QX present → 50% of the running amount
  18. cap each charge and the account total at 100% of billed charges
Humana-Medicare5 base · 19 adj
Humana Medicare
Profee · all facilities · 2023-01-01 → 2999-12-31
Base terms — first match wins
  1. 0% of billed charges — when NonCovered NC is present
  2. 100% of Medicare lab
  3. 100% of Medicare drug
  4. 100% of Medicare DME
  5. 100% of Medicare RVU
Adjustments — all apply, in order
  1. Medicare multiple-procedure reduction — base codes 2, 3; pays 100/50%
  2. Medicare multiple-radiology reduction — base codes 7
  3. Medicare multiple-endoscopy reduction
  4. Medicare multiple-radiology reduction — base codes 4
  5. mid-level provider reduction (by NUCC taxonomy)
  6. modifier 22 present → 135% of the running amount
  7. modifier 50 present → 150% of the running amount
  8. modifier 52 present → 50% of the running amount
  9. modifier 54 present → 80% of the running amount
  10. modifier 62 present → 62.5% of the running amount
  11. modifier 78 present → 70% of the running amount
  12. modifier 80 present → 16% of the running amount
  13. modifier 81 present → 16% of the running amount
  14. modifier 82 present → 16% of the running amount
  15. modifier AS present → 14% of the running amount
  16. modifier QY present → 50% of the running amount
  17. modifier QK present → 50% of the running amount
  18. modifier QX present → 50% of the running amount
  19. cap each charge and the account total at 100% of billed charges
Humana-Medicare-ASC1 base · 18 adj
Humana Medicare
Facility · all facilities · 2023-01-01 → 2999-12-31
Base terms — first match wins
  1. 100% of Medicare ASC
Adjustments — all apply, in order
  1. Medicare multiple-procedure reduction — base codes 2, 3; pays 100/50%
  2. Medicare multiple-endoscopy reduction
  3. Medicare multiple-radiology reduction
  4. mid-level provider reduction (by NUCC taxonomy)
  5. modifier 22 present → 135% of the running amount
  6. modifier 50 present → 150% of the running amount
  7. modifier 52 present → 50% of the running amount
  8. modifier 54 present → 80% of the running amount
  9. modifier 62 present → 62.5% of the running amount
  10. modifier 78 present → 70% of the running amount
  11. modifier 80 present → 16% of the running amount
  12. modifier 81 present → 16% of the running amount
  13. modifier 82 present → 16% of the running amount
  14. modifier AS present → 14% of the running amount
  15. modifier QY present → 50% of the running amount
  16. modifier QK present → 50% of the running amount
  17. modifier QX present → 50% of the running amount
  18. cap each charge and the account total at 100% of billed charges
Medicare5 base · 19 adj
Medicare
Profee · all facilities · 2023-01-01 → 2999-12-31
BCBS Medicare Advantage
Profee · all facilities · 2023-01-01 → 2999-12-31
Base terms — first match wins
  1. 0% of billed charges — when NonCovered NC is present
  2. 100% of Medicare lab
  3. 100% of Medicare drug
  4. 100% of Medicare DME
  5. 100% of Medicare RVU
Adjustments — all apply, in order
  1. Medicare multiple-procedure reduction — base codes 2, 3; pays 100/50%
  2. Medicare multiple-radiology reduction — base codes 7
  3. Medicare multiple-endoscopy reduction
  4. Medicare multiple-radiology reduction — base codes 4
  5. mid-level provider reduction (by NUCC taxonomy)
  6. modifier 22 present → 135% of the running amount
  7. modifier 50 present → 150% of the running amount
  8. modifier 52 present → 50% of the running amount
  9. modifier 54 present → 80% of the running amount
  10. modifier 62 present → 62.5% of the running amount
  11. modifier 78 present → 70% of the running amount
  12. modifier 80 present → 16% of the running amount
  13. modifier 81 present → 16% of the running amount
  14. modifier 82 present → 16% of the running amount
  15. modifier AS present → 14% of the running amount
  16. modifier QY present → 50% of the running amount
  17. modifier QK present → 50% of the running amount
  18. modifier QX present → 50% of the running amount
  19. cap each charge and the account total at 100% of billed charges
Medicare-ASC1 base · 18 adj
Medicare
Facility · all facilities · 2023-01-01 → 2999-12-31
Base terms — first match wins
  1. 100% of Medicare ASC
Adjustments — all apply, in order
  1. Medicare multiple-procedure reduction — base codes 2, 3; pays 100/50%
  2. Medicare multiple-endoscopy reduction
  3. Medicare multiple-radiology reduction — base codes 4
  4. mid-level provider reduction (by NUCC taxonomy)
  5. modifier 22 present → 135% of the running amount
  6. modifier 50 present → 150% of the running amount
  7. modifier 52 present → 50% of the running amount
  8. modifier 54 present → 80% of the running amount
  9. modifier 62 present → 62.5% of the running amount
  10. modifier 78 present → 70% of the running amount
  11. modifier 80 present → 16% of the running amount
  12. modifier 81 present → 16% of the running amount
  13. modifier 82 present → 16% of the running amount
  14. modifier AS present → 14% of the running amount
  15. modifier QY present → 50% of the running amount
  16. modifier QK present → 50% of the running amount
  17. modifier QX present → 50% of the running amount
  18. cap each charge and the account total at 100% of billed charges
Self-Pay1 base · 0 adj
Self Pay
Profee · all facilities · 2023-01-01 → 2999-12-31
Base terms — first match wins
  1. 100% of the Profee-Fees fee schedule
Texas Medicaid Profees1 base · 18 adj
Medicaid
Profee · all facilities · 2023-01-01 → 2999-12-31
Base terms — first match wins
  1. custom SQL — Looks up a Texas Medicaid professional fee for a charge's procedure+modifier+patient-age bracket, using a Clinic vs Facility rate column chosen by the billing facility's type, taking the most recently effective matching row as of the service date.
Adjustments — all apply, in order
  1. Medicare multiple-procedure reduction — base codes 2, 3; pays 100/50%
  2. Medicare multiple-endoscopy reduction
  3. Medicare multiple-radiology reduction — base codes 4
  4. mid-level provider reduction (by NUCC taxonomy)
  5. modifier 22 present → 135% of the running amount
  6. modifier 50 present → 150% of the running amount
  7. modifier 52 present → 50% of the running amount
  8. modifier 54 present → 80% of the running amount
  9. modifier 62 present → 62.5% of the running amount
  10. modifier 78 present → 70% of the running amount
  11. modifier 80 present → 16% of the running amount
  12. modifier 81 present → 16% of the running amount
  13. modifier 82 present → 16% of the running amount
  14. modifier AS present → 14% of the running amount
  15. modifier QY present → 50% of the running amount
  16. modifier QK present → 50% of the running amount
  17. modifier QX present → 50% of the running amount
  18. cap each charge and the account total at 100% of billed charges
UHC2 base · 20 adj
UHC
Profee · all facilities · 2023-01-01 → 2999-12-31
Base terms — first match wins
  1. custom SQL — Zeroes the allowed amount for two specific drug HCPCS codes (J1097, J1096) — an unconditional 'no separate payment' exclusion for those two codes.
  2. 100% of the Profee-Fees fee schedule
Adjustments — all apply, in order
  1. Medicare multiple-procedure reduction — base codes 2, 3; pays 100/50%
  2. Medicare multiple-radiology reduction — base codes 7
  3. Medicare multiple-endoscopy reduction
  4. Medicare multiple-radiology reduction — base codes 4
  5. mid-level provider reduction (by NUCC taxonomy)
  6. modifier 22 present → 135% of the running amount
  7. modifier 50 present → 150% of the running amount
  8. modifier 52 present → 50% of the running amount
  9. modifier 54 present → 80% of the running amount
  10. modifier 62 present → 62.5% of the running amount
  11. modifier 78 present → 70% of the running amount
  12. modifier 80 present → 16% of the running amount
  13. modifier 81 present → 16% of the running amount
  14. modifier 82 present → 16% of the running amount
  15. modifier AS present → 14% of the running amount
  16. modifier QY present → 50% of the running amount
  17. modifier QK present → 50% of the running amount
  18. modifier QX present → 50% of the running amount
  19. modifier QZ present → 85% of the running amount
  20. cap each charge and the account total at 100% of billed charges
UHC Medicaid Profee1 base · 18 adj
UHC Medicaid
Profee · all facilities · 2023-01-01 → 2999-12-31
Base terms — first match wins
  1. custom SQL — Looks up a Texas Medicaid professional fee for a charge's procedure+modifier+patient-age bracket, using a Clinic vs Facility rate column chosen by the billing facility's type, taking the most recently effective matching row as of the service date.
Adjustments — all apply, in order
  1. Medicare multiple-procedure reduction — base codes 2, 3; pays 100/50%
  2. Medicare multiple-endoscopy reduction
  3. Medicare multiple-radiology reduction — base codes 4
  4. mid-level provider reduction (by NUCC taxonomy)
  5. modifier 22 present → 135% of the running amount
  6. modifier 50 present → 150% of the running amount
  7. modifier 52 present → 50% of the running amount
  8. modifier 54 present → 80% of the running amount
  9. modifier 62 present → 62.5% of the running amount
  10. modifier 78 present → 70% of the running amount
  11. modifier 80 present → 16% of the running amount
  12. modifier 81 present → 16% of the running amount
  13. modifier 82 present → 16% of the running amount
  14. modifier AS present → 14% of the running amount
  15. modifier QY present → 50% of the running amount
  16. modifier QK present → 50% of the running amount
  17. modifier QX present → 50% of the running amount
  18. cap each charge and the account total at 100% of billed charges
UHC-Facility2 base · 19 adj
UHC
Facility · all facilities · 2024-07-01 → 2999-12-31
Base terms — first match wins
  1. custom SQL — Zeroes the allowed amount for two specific drug HCPCS codes (J1097, J1096) — an unconditional 'no separate payment' exclusion for those two codes.
  2. 100% of the Facility-Fees fee schedule
Adjustments — all apply, in order
  1. Medicare multiple-procedure reduction — base codes 2, 3; pays 100/50/25%
  2. Medicare multiple-endoscopy reduction
  3. Medicare multiple-radiology reduction — base codes 4
  4. mid-level provider reduction (by NUCC taxonomy)
  5. modifier 22 present → 135% of the running amount
  6. modifier 50 present → 150% of the running amount
  7. modifier 52 present → 50% of the running amount
  8. modifier 54 present → 80% of the running amount
  9. modifier 62 present → 62.5% of the running amount
  10. modifier 78 present → 70% of the running amount
  11. modifier 80 present → 16% of the running amount
  12. modifier 81 present → 16% of the running amount
  13. modifier 82 present → 16% of the running amount
  14. modifier AS present → 14% of the running amount
  15. modifier QY present → 50% of the running amount
  16. modifier QK present → 50% of the running amount
  17. modifier QX present → 50% of the running amount
  18. modifier QZ present → 85% of the running amount
  19. cap each charge and the account total at 100% of billed charges
UHC-Medicare5 base · 20 adj
UHC Medicare
Profee · all facilities · 2023-01-01 → 2999-12-31
Base terms — first match wins
  1. 0% of billed charges — when NonCovered NC is present
  2. 100% of Medicare lab
  3. 100% of Medicare drug
  4. 100% of Medicare DME
  5. 100% of Medicare RVU
Adjustments — all apply, in order
  1. Medicare multiple-procedure reduction — base codes 2, 3; pays 100/50%
  2. Medicare multiple-radiology reduction — base codes 7
  3. Medicare multiple-endoscopy reduction
  4. Medicare multiple-radiology reduction — base codes 4
  5. mid-level provider reduction (by NUCC taxonomy)
  6. modifier 22 present → 135% of the running amount
  7. modifier 50 present → 150% of the running amount
  8. modifier 52 present → 50% of the running amount
  9. modifier 54 present → 80% of the running amount
  10. modifier 62 present → 62.5% of the running amount
  11. modifier 78 present → 70% of the running amount
  12. modifier 80 present → 16% of the running amount
  13. modifier 81 present → 16% of the running amount
  14. modifier 82 present → 16% of the running amount
  15. modifier AS present → 14% of the running amount
  16. modifier QY present → 50% of the running amount
  17. modifier QK present → 50% of the running amount
  18. modifier QX present → 50% of the running amount
  19. modifier QZ present → 85% of the running amount
  20. cap each charge and the account total at 100% of billed charges
UHC-Medicare-ASC-20241 base · 19 adj
UHC Medicare
Facility · all facilities · 2023-01-01 → 2024-12-31
Base terms — first match wins
  1. 95% of Medicare ASC
Adjustments — all apply, in order
  1. Medicare multiple-procedure reduction — base codes 2, 3; pays 100/50%
  2. Medicare multiple-endoscopy reduction
  3. Medicare multiple-radiology reduction — base codes 4
  4. mid-level provider reduction (by NUCC taxonomy)
  5. modifier 22 present → 135% of the running amount
  6. modifier 50 present → 150% of the running amount
  7. modifier 52 present → 50% of the running amount
  8. modifier 54 present → 80% of the running amount
  9. modifier 62 present → 62.5% of the running amount
  10. modifier 78 present → 70% of the running amount
  11. modifier 80 present → 16% of the running amount
  12. modifier 81 present → 16% of the running amount
  13. modifier 82 present → 16% of the running amount
  14. modifier AS present → 14% of the running amount
  15. modifier QY present → 50% of the running amount
  16. modifier QK present → 50% of the running amount
  17. modifier QX present → 50% of the running amount
  18. modifier QZ present → 85% of the running amount
  19. cap each charge and the account total at 100% of billed charges
UHC-Medicare-ASC-20253 base · 19 adj
UHC Medicare
Facility · all facilities · 2025-01-01 → 2999-12-31
Base terms — first match wins
  1. 35% of billed charges — when ProcedureCode C9399 is present
  2. 95% of Medicare ASC
  3. 0% of the NonCoveredServices fee schedule
Adjustments — all apply, in order
  1. Medicare multiple-procedure reduction — base codes 2, 3; pays 100/50%
  2. Medicare multiple-endoscopy reduction
  3. Medicare multiple-radiology reduction — base codes 4
  4. mid-level provider reduction (by NUCC taxonomy)
  5. modifier 22 present → 135% of the running amount
  6. modifier 50 present → 150% of the running amount
  7. modifier 52 present → 50% of the running amount
  8. modifier 54 present → 80% of the running amount
  9. modifier 62 present → 62.5% of the running amount
  10. modifier 78 present → 70% of the running amount
  11. modifier 80 present → 16% of the running amount
  12. modifier 81 present → 16% of the running amount
  13. modifier 82 present → 16% of the running amount
  14. modifier AS present → 14% of the running amount
  15. modifier QY present → 50% of the running amount
  16. modifier QK present → 50% of the running amount
  17. modifier QX present → 50% of the running amount
  18. modifier QZ present → 85% of the running amount
  19. cap each charge and the account total at 100% of billed charges

Cannot fire (6)

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

95% Medicare Rate - Profees · no contract map5 base · 18 adj
no contract map — cannot be resolved
Base terms — first match wins
  1. 0% of billed charges — when NonCovered NC is present
  2. 95% of Medicare lab
  3. 95% of Medicare drug
  4. 95% of Medicare DME
  5. 95% of Medicare RVU
Adjustments — all apply, in order
  1. multiple-procedure reduction (contract rules) — base codes 2, 3; pays 100/50%
  2. multiple-endoscopy reduction (contract rules)
  3. multiple-radiology reduction (contract rules)
  4. rescale by a percentage read from the Mid-Level-Provider schedule
  5. modifier 22 present → 135% of the running amount
  6. modifier 50 present → 150% of the running amount
  7. modifier 52 present → 50% of the running amount
  8. modifier 54 present → 80% of the running amount
  9. modifier 62 present → 62.5% of the running amount
  10. modifier 78 present → 70% of the running amount
  11. modifier 80 present → 16% of the running amount
  12. modifier 81 present → 16% of the running amount
  13. modifier 82 present → 16% of the running amount
  14. modifier AS present → 14% of the running amount
  15. modifier QY present → 50% of the running amount
  16. modifier QK present → 50% of the running amount
  17. modifier QX present → 50% of the running amount
  18. cap each charge and the account total at 100% of billed charges
95%-Medicare-ASC · no contract map2 base · 18 adj
no contract map — cannot be resolved
Base terms — first match wins
  1. 95% of Medicare ASC
  2. 95% of the Medicare-ASC fee schedule ⚠︎ named “100% Medicare ASC Fee Schedule” but configured at 95%
Adjustments — all apply, in order
  1. multiple-procedure reduction (contract rules) — base codes 2, 3; pays 100/50%
  2. multiple-endoscopy reduction (contract rules)
  3. multiple-radiology reduction (contract rules)
  4. rescale by a percentage read from the Mid-Level-Provider schedule
  5. modifier 22 present → 135% of the running amount
  6. modifier 50 present → 150% of the running amount
  7. modifier 52 present → 50% of the running amount
  8. modifier 54 present → 80% of the running amount
  9. modifier 62 present → 62.5% of the running amount
  10. modifier 78 present → 70% of the running amount
  11. modifier 80 present → 16% of the running amount
  12. modifier 81 present → 16% of the running amount
  13. modifier 82 present → 16% of the running amount
  14. modifier AS present → 14% of the running amount
  15. modifier QY present → 50% of the running amount
  16. modifier QK present → 50% of the running amount
  17. modifier QX present → 50% of the running amount
  18. cap each charge and the account total at 100% of billed charges
Aetna · no contract map13 base · 18 adj
no contract map — cannot be resolved
Base terms — first match wins
  1. custom SQL — Hard override that zeroes out any charge billed under drug code J1097.
  2. 100% of the AetnaCarveOuts fee schedule
  3. 135% of Medicare RVU — when CPTCategories-Aetna Evaluation and Management is present
  4. 125% of the Profee-Fees fee schedule — when CPTCategories-Aetna Drugs is present
  5. 125% of the Profee-Fees fee schedule — when CPTCategories-Aetna Medicine is present
  6. 125% of the Profee-Fees fee schedule — when CPTCategories-Aetna Immunizations is present
  7. 125% of the Profee-Fees fee schedule — when CPTCategories-Aetna Laboratory is present
  8. 125% of the Profee-Fees fee schedule — when CPTCategories-Aetna Radiology is present
  9. 150% of Medicare lab
  10. 150% of Medicare drug
  11. 150% of Medicare DME
  12. 150% of Medicare RVU
  13. 0% of billed charges — when PropertyTypeRule in NC
Adjustments — all apply, in order
  1. multiple-procedure reduction (contract rules) — base codes 2, 3; pays 100/50%
  2. multiple-endoscopy reduction (contract rules)
  3. multiple-radiology reduction (contract rules) — base codes 4
  4. rescale by a percentage read from the Mid-Level-Provider schedule
  5. modifier 22 present → 135% of the running amount
  6. modifier 50 present → 150% of the running amount
  7. modifier 52 present → 50% of the running amount
  8. modifier 54 present → 80% of the running amount
  9. modifier 62 present → 62.5% of the running amount
  10. modifier 78 present → 70% of the running amount
  11. modifier 80 present → 16% of the running amount
  12. modifier 81 present → 16% of the running amount
  13. modifier 82 present → 16% of the running amount
  14. modifier AS present → 14% of the running amount
  15. modifier QY present → 50% of the running amount
  16. modifier QK present → 50% of the running amount
  17. modifier QX present → 50% of the running amount
  18. cap each charge and the account total at 100% of billed charges
Aetna-Medicare-HLSC-ASC · no contract map1 base · 18 adj
no contract map — cannot be resolved
Base terms — first match wins
  1. 100% of Medicare ASC
Adjustments — all apply, in order
  1. Medicare multiple-procedure reduction — base codes 2, 3; pays 100/50%
  2. Medicare multiple-endoscopy reduction
  3. Medicare multiple-radiology reduction — base codes 4
  4. mid-level provider reduction (by NUCC taxonomy)
  5. modifier 22 present → 135% of the running amount
  6. modifier 50 present → 150% of the running amount
  7. modifier 52 present → 50% of the running amount
  8. modifier 54 present → 80% of the running amount
  9. modifier 62 present → 62.5% of the running amount
  10. modifier 78 present → 70% of the running amount
  11. modifier 80 present → 16% of the running amount
  12. modifier 81 present → 16% of the running amount
  13. modifier 82 present → 16% of the running amount
  14. modifier AS present → 14% of the running amount
  15. modifier QY present → 50% of the running amount
  16. modifier QK present → 50% of the running amount
  17. modifier QX present → 50% of the running amount
  18. cap each charge and the account total at 100% of billed charges
Cigna-Commercial-Facility-Profees · no contract map3 base · 18 adj
no contract map — cannot be resolved
Base terms — first match wins
  1. custom SQL — Zeroes the allowed amount for two specific drug HCPCS codes (J1097, J1096) — an unconditional 'no separate payment' exclusion for those two codes.
  2. 100% of the Facility-Profee-Fees fee schedule
  3. percent-of-charges, rate read from the None schedule
Adjustments — all apply, in order
  1. Medicare multiple-procedure reduction — base codes 2, 3; pays 100/50%
  2. Medicare multiple-endoscopy reduction
  3. Medicare multiple-radiology reduction — base codes 4
  4. mid-level provider reduction (by NUCC taxonomy)
  5. modifier 22 present → 135% of the running amount
  6. modifier 50 present → 150% of the running amount
  7. modifier 52 present → 50% of the running amount
  8. modifier 54 present → 80% of the running amount
  9. modifier 62 present → 62.5% of the running amount
  10. modifier 78 present → 70% of the running amount
  11. modifier 80 present → 16% of the running amount
  12. modifier 81 present → 16% of the running amount
  13. modifier 82 present → 16% of the running amount
  14. modifier AS present → 14% of the running amount
  15. modifier QY present → 50% of the running amount
  16. modifier QK present → 50% of the running amount
  17. modifier QX present → 50% of the running amount
  18. cap each charge and the account total at 100% of billed charges
UHC-Medicare-ASC · no contract map2 base · 18 adj
no contract map — cannot be resolved
Base terms — first match wins
  1. 100% of Medicare ASC
  2. 100% of the Medicare-ASC fee schedule
Adjustments — all apply, in order
  1. Medicare multiple-procedure reduction — base codes 2, 3; pays 100/50%
  2. Medicare multiple-endoscopy reduction
  3. Medicare multiple-radiology reduction
  4. mid-level provider reduction (by NUCC taxonomy)
  5. modifier 22 present → 135% of the running amount
  6. modifier 50 present → 150% of the running amount
  7. modifier 52 present → 50% of the running amount
  8. modifier 54 present → 80% of the running amount
  9. modifier 62 present → 62.5% of the running amount
  10. modifier 78 present → 70% of the running amount
  11. modifier 80 present → 16% of the running amount
  12. modifier 81 present → 16% of the running amount
  13. modifier 82 present → 16% of the running amount
  14. modifier AS present → 14% of the running amount
  15. modifier QY present → 50% of the running amount
  16. modifier QK present → 50% of the running amount
  17. modifier QX present → 50% of the running amount
  18. cap each charge and the account total at 100% of billed charges