Customer detail

HillsboroEye

11
live contracts
1
cannot fire
17
calc types
1
SQL bodies
0
of those blocked
0
map conflicts

Methodology mix

ModifierAdjustment132
MedicareRVU32
FlatFee12
LesserOfAdjustment12
MedicareMultipleProcedureAdjustment12
ChargeLevelSqlAdjustment12
MedicareBilateralSurgeryAdjustment12
MedicareMultipleEndoscopyAdjustment12
MedicareMultipleRadiologyAdjustment12
FlatPercentOfCharges11
MidLevelProviderAdjustment11
MedicareLab11
MedicareDrug10
MedicareDME9
PercentOfFees6
PercentOfCharges1
MedicareAnesthesia1

Contracts

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

Aetna-Commercial-Profee5 base · 18 adj
Aetna
Professional · all facilities · 2026-04-01 → 2999-12-31
Base terms — first match wins
  1. flat $0 — when NoncoverageStatus Noncovered is present
  2. 100% of Medicare lab (rates as of 2025-01-01)
  3. 100% of Medicare drug
  4. 100% of Medicare RVU (rates as of 2025-01-01)
    • CodeRange 10040–79999 → 273.41%
    • CodeRange 90785–99499 → 273.41%
  5. 0% of billed charges
Adjustments — all apply, in order
  1. Medicare multiple-endoscopy reduction
  2. Medicare multiple-radiology reduction — base codes 4
  3. Medicare bilateral-surgery adjustment
  4. Medicare multiple-procedure reduction — base codes 2, 3; pays 100/50%
  5. mid-level provider reduction (by NUCC taxonomy)
  6. modifier 22 present → 135% of the running amount
  7. modifier 54 present → 80% of the running amount
  8. custom SQL — Allocates a global-surgery-period allowed amount to its post-operative portion: pulls a procedure's POST_OP percentage and GLOB_DAYS (global period length) from Medicare RVU reference data and returns Allowed / GlobalDays * PostOpRate — i.e. a per-day post-op share of the total global allowed amount. — when Modifier 55 is present
  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-Profee4 base · 18 adj
Cigna
Professional · all facilities · 2024-01-01 → 2999-12-31
Base terms — first match wins
  1. flat $0 — when NoncoverageStatus Noncovered is present
  2. 100% of the Cigna-Commercial-NonFacility-Profee fee schedule — when FacilityType in Clinic
  3. 100% of the Cigna-Commercial-Facility-Profee fee schedule — when FacilityType in ASC, Home, Hospital
  4. 80% of billed charges
Adjustments — all apply, in order
  1. Medicare multiple-endoscopy reduction
  2. Medicare multiple-radiology reduction — base codes 4
  3. Medicare bilateral-surgery adjustment
  4. Medicare multiple-procedure reduction — base codes 2, 3; pays 100/50%
  5. mid-level provider reduction (by NUCC taxonomy)
  6. modifier 22 present → 135% of the running amount
  7. modifier 54 present → 80% of the running amount
  8. custom SQL — Allocates a global-surgery-period allowed amount to its post-operative portion: pulls a procedure's POST_OP percentage and GLOB_DAYS (global period length) from Medicare RVU reference data and returns Allowed / GlobalDays * PostOpRate — i.e. a per-day post-op share of the total global allowed amount. — when Modifier 55 is present
  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-Medicare- Profee8 base · 18 adj
Humana Medicare
Professional · all facilities · 2024-01-01 → 2999-12-31
Base terms — first match wins
  1. flat $0 — when NoncoverageStatus Noncovered is present
  2. 100% of Medicare RVU
    • CodeRange 90000–99999 → 106%
    • CodeRange 10000–69999 → 106%
  3. 100% of Medicare drug
  4. 100% of Medicare DME
  5. 100% of Medicare lab
  6. 100% of the Humana-Medicare-005/973-NonFacility-Profee fee schedule — when FacilityType in Clinic
  7. 100% of the Humana-Medicare-005/973-Facility-Profee fee schedule — when FacilityType in ASC, Home, Hospital
  8. 0% of billed charges
Adjustments — all apply, in order
  1. Medicare multiple-endoscopy reduction
  2. Medicare multiple-radiology reduction — base codes 4
  3. Medicare bilateral-surgery adjustment
  4. Medicare multiple-procedure reduction — base codes 2, 3; pays 100/50%
  5. mid-level provider reduction (by NUCC taxonomy)
  6. modifier 22 present → 135% of the running amount
  7. modifier 54 present → 80% of the running amount
  8. custom SQL — Allocates a global-surgery-period allowed amount to its post-operative portion: pulls a procedure's POST_OP percentage and GLOB_DAYS (global period length) from Medicare RVU reference data and returns Allowed / GlobalDays * PostOpRate — i.e. a per-day post-op share of the total global allowed amount. — when Modifier 55 is present
  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
Medicare6 base · 18 adj
Medicare
Professional · all facilities · 2024-01-01 → 2999-12-31
Base terms — first match wins
  1. flat $0 — when NoncoverageStatus Noncovered is present
  2. 100% of Medicare lab
  3. 100% of Medicare drug
  4. 100% of Medicare DME
  5. 100% of Medicare RVU
  6. 100% of Medicare anesthesia
Adjustments — all apply, in order
  1. Medicare multiple-endoscopy reduction
  2. Medicare multiple-radiology reduction — base codes 4
  3. Medicare bilateral-surgery adjustment
  4. Medicare multiple-procedure reduction — base codes 2, 3; pays 100/50%
  5. mid-level provider reduction (by NUCC taxonomy)
  6. modifier 22 present → 135% of the running amount
  7. modifier 54 present → 80% of the running amount
  8. custom SQL — Allocates a global-surgery-period allowed amount to its post-operative portion: pulls a procedure's POST_OP percentage and GLOB_DAYS (global period length) from Medicare RVU reference data and returns Allowed / GlobalDays * PostOpRate — i.e. a per-day post-op share of the total global allowed amount. — when Modifier 55 is present
  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
Moda-Commercial-Profee9 base · 17 adj
MODA
Professional · all facilities · 2026-01-01 → 2999-12-31
Base terms — first match wins
  1. flat $0 — when NoncoverageStatus Noncovered is present
  2. percent-of-charges, rate read from the Moda-Commercial-POC-Profee schedule
  3. 100% of Medicare lab (rates as of 2025-01-01)
  4. 100% of Medicare drug
  5. 100% of Medicare DME (rates as of 2025-01-01)
  6. 100% of Medicare RVU — when CodeRange in 92002–92015
  7. 100% of Medicare RVU (rates as of 2025-01-01)
  8. 100% of Medicare RVU (rates as of 2025-01-01)
  9. 60% of billed charges
Adjustments — all apply, in order
  1. Medicare multiple-endoscopy reduction
  2. Medicare multiple-radiology reduction — base codes 4
  3. Medicare bilateral-surgery adjustment
  4. Medicare multiple-procedure reduction — base codes 2, 3; pays 100/50%
  5. modifier 22 present → 135% of the running amount
  6. modifier 54 present → 80% of the running amount
  7. custom SQL — Allocates a global-surgery-period allowed amount to its post-operative portion: pulls a procedure's POST_OP percentage and GLOB_DAYS (global period length) from Medicare RVU reference data and returns Allowed / GlobalDays * PostOpRate — i.e. a per-day post-op share of the total global allowed amount. — when Modifier 55 is present
  8. modifier 62 present → 62.5% of the running amount
  9. modifier 78 present → 70% of the running amount
  10. modifier 80 present → 16% of the running amount
  11. modifier 81 present → 16% of the running amount
  12. modifier 82 present → 16% of the running amount
  13. modifier AS present → 14% of the running amount
  14. modifier QY present → 50% of the running amount
  15. modifier QK present → 50% of the running amount
  16. modifier QX present → 50% of the running amount
  17. cap each charge and the account total at 100% of billed charges
OHSU-Medicaid-Profee4 base · 18 adj
OHSU
Professional · all facilities · 2025-01-01 → 2999-12-31
Base terms — first match wins
  1. flat $0 — when NoncoverageStatus Noncovered is present
  2. 100% of the OHSU-Medicaid-DMAP-NonFacility-Profee fee schedule — when FacilityType in Clinic
    • CodeRange 90000–99999 → 110%
    • CodeRange 10000–79999 → 110%
  3. 100% of the OHSU-Medicaid-DMAP-Facility-Profee fee schedule
    • CodeRange 90000–99999 → 110%
    • CodeRange 10000–79999 → 110%
  4. 0% of billed charges
Adjustments — all apply, in order
  1. Medicare multiple-endoscopy reduction
  2. Medicare multiple-radiology reduction — base codes 4
  3. Medicare bilateral-surgery adjustment
  4. Medicare multiple-procedure reduction — base codes 2, 3; pays 100/50%
  5. mid-level provider reduction (by NUCC taxonomy)
  6. modifier 22 present → 135% of the running amount
  7. modifier 54 present → 80% of the running amount
  8. custom SQL — Allocates a global-surgery-period allowed amount to its post-operative portion: pulls a procedure's POST_OP percentage and GLOB_DAYS (global period length) from Medicare RVU reference data and returns Allowed / GlobalDays * PostOpRate — i.e. a per-day post-op share of the total global allowed amount. — when Modifier 55 is present
  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
Regence-Commercial-Profee24 base · 18 adj
Regence
Professional · all facilities · 2025-01-01 → 2999-12-31
Base terms — first match wins
  1. flat $0 — when NoncoverageStatus Noncovered is present
  2. 85% of Medicare lab
  3. 103% of Medicare drug
  4. 110% of Medicare DME
  5. 100% of Medicare RVU (rates as of 2024-01-01) — when CodeRange in 98925–98929
  6. 100% of Medicare RVU (rates as of 2024-01-01) — when CodeRange in 98940–98943
  7. 100% of Medicare RVU (rates as of 2024-01-01) — when CodeRange in 99200–99499
  8. 100% of Medicare RVU (rates as of 2024-01-01) — when CodeRange in 92002–92014
  9. 100% of Medicare RVU (rates as of 2024-01-01) — when CodeRange in 70000–79999
  10. 100% of Medicare RVU (rates as of 2024-01-01) — when CodeRange in 10000–69999
  11. 100% of Medicare RVU (rates as of 2024-01-01) — when CodeRange in 92507–92508
  12. 100% of Medicare RVU (rates as of 2024-01-01) — when CodeRange in 92597–92597
  13. 100% of Medicare RVU (rates as of 2024-01-01) — when CodeRange in 97001–97546
  14. 100% of Medicare RVU (rates as of 2024-01-01) — when CodeRange in 90000–91999
  15. 100% of Medicare RVU (rates as of 2024-01-01) — when CodeRange in 92015–92506
  16. 100% of Medicare RVU (rates as of 2024-01-01) — when CodeRange in 92509–92596
  17. 100% of Medicare RVU (rates as of 2024-01-01) — when CodeRange in 92598–92606
  18. 100% of Medicare RVU (rates as of 2024-01-01) — when CodeRange in 92609–97000
  19. 100% of Medicare RVU (rates as of 2024-01-01) — when CodeRange in 97547–98924
  20. 100% of Medicare RVU (rates as of 2024-01-01) — when CodeRange in 98930–98939
  21. 100% of Medicare RVU (rates as of 2024-01-01) — when CodeRange in 98944–99199
  22. 100% of Medicare RVU (rates as of 2024-01-01) — when CodeRange in 99500–99999
  23. 100% of Medicare RVU (rates as of 2024-01-01)
  24. 0% of billed charges
Adjustments — all apply, in order
  1. Medicare multiple-endoscopy reduction
  2. Medicare multiple-radiology reduction — base codes 4
  3. Medicare bilateral-surgery adjustment
  4. Medicare multiple-procedure reduction — base codes 2, 3; pays 100/50%
  5. mid-level provider reduction (by NUCC taxonomy)
  6. modifier 22 present → 135% of the running amount
  7. modifier 54 present → 80% of the running amount
  8. custom SQL — Allocates a global-surgery-period allowed amount to its post-operative portion: pulls a procedure's POST_OP percentage and GLOB_DAYS (global period length) from Medicare RVU reference data and returns Allowed / GlobalDays * PostOpRate — i.e. a per-day post-op share of the total global allowed amount. — when Modifier 55 is present
  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
Regence-Medicare-HMO-Profee6 base · 18 adj
Regence Medicare HMO
Professional · all facilities · 2025-01-01 → 2999-12-31
Base terms — first match wins
  1. flat $0 — when NoncoverageStatus Noncovered is present
  2. 100% of Medicare lab
  3. 100% of Medicare drug
  4. 100% of Medicare DME
  5. 105% of Medicare RVU
  6. 0% of billed charges
Adjustments — all apply, in order
  1. Medicare multiple-endoscopy reduction
  2. Medicare multiple-radiology reduction — base codes 4
  3. Medicare bilateral-surgery adjustment
  4. Medicare multiple-procedure reduction — base codes 2, 3; pays 100/50%
  5. mid-level provider reduction (by NUCC taxonomy)
  6. modifier 22 present → 135% of the running amount
  7. modifier 54 present → 80% of the running amount
  8. custom SQL — Allocates a global-surgery-period allowed amount to its post-operative portion: pulls a procedure's POST_OP percentage and GLOB_DAYS (global period length) from Medicare RVU reference data and returns Allowed / GlobalDays * PostOpRate — i.e. a per-day post-op share of the total global allowed amount. — when Modifier 55 is present
  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
Regence-Medicare-PPO-Profee6 base · 18 adj
Regence Medicare PPO
Professional · all facilities · 2025-01-01 → 2999-12-31
Base terms — first match wins
  1. flat $0 — when NoncoverageStatus Noncovered is present
  2. 100% of Medicare lab
  3. 100% of Medicare drug
  4. 100% of Medicare DME
  5. 105% of Medicare RVU
    • CodeRange 90000–99999 → 110%
    • CodeRange 10000–69999 → 110%
    • CodeRange 70000–79999 → 110%
  6. 0% of billed charges
Adjustments — all apply, in order
  1. Medicare multiple-endoscopy reduction
  2. Medicare multiple-radiology reduction — base codes 4
  3. Medicare bilateral-surgery adjustment
  4. Medicare multiple-procedure reduction — base codes 2, 3; pays 100/50%
  5. mid-level provider reduction (by NUCC taxonomy)
  6. modifier 22 present → 135% of the running amount
  7. modifier 54 present → 80% of the running amount
  8. custom SQL — Allocates a global-surgery-period allowed amount to its post-operative portion: pulls a procedure's POST_OP percentage and GLOB_DAYS (global period length) from Medicare RVU reference data and returns Allowed / GlobalDays * PostOpRate — i.e. a per-day post-op share of the total global allowed amount. — when Modifier 55 is present
  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-Commercial-Profee8 base · 18 adj
UHC
Professional · all facilities · 2025-01-01 → 2999-12-31
Base terms — first match wins
  1. flat $0 — when NoncoverageStatus Noncovered is present
  2. 40% of Medicare lab — when Modifier QW is present
  3. 60% of Medicare lab
  4. 120% of Medicare drug
  5. 60% of Medicare DME
  6. 228.26% of Medicare RVU (rates as of 2023-01-01) — when CodeRange in 70000–79999
  7. 100% of Medicare RVU (rates as of 2023-01-01)
  8. 40% of billed charges
Adjustments — all apply, in order
  1. Medicare multiple-endoscopy reduction
  2. Medicare multiple-radiology reduction — base codes 4
  3. Medicare bilateral-surgery adjustment
  4. Medicare multiple-procedure reduction — base codes 2, 3; pays 100/50%
  5. mid-level provider reduction (by NUCC taxonomy)
  6. modifier 22 present → 135% of the running amount
  7. modifier 54 present → 80% of the running amount
  8. custom SQL — Allocates a global-surgery-period allowed amount to its post-operative portion: pulls a procedure's POST_OP percentage and GLOB_DAYS (global period length) from Medicare RVU reference data and returns Allowed / GlobalDays * PostOpRate — i.e. a per-day post-op share of the total global allowed amount. — when Modifier 55 is present
  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-Profee6 base · 18 adj
UHC Medicare
Professional · all facilities · 2024-01-01 → 2999-12-31
Base terms — first match wins
  1. flat $0 — when NoncoverageStatus Noncovered is present
  2. 60% of Medicare lab
  3. 110% of Medicare drug
  4. 65% of Medicare DME
  5. 110% of Medicare RVU
  6. 35% of billed charges
Adjustments — all apply, in order
  1. Medicare multiple-endoscopy reduction
  2. Medicare multiple-radiology reduction — base codes 4
  3. Medicare bilateral-surgery adjustment
  4. Medicare multiple-procedure reduction — base codes 2, 3; pays 100/50%
  5. mid-level provider reduction (by NUCC taxonomy)
  6. modifier 22 present → 135% of the running amount
  7. modifier 54 present → 80% of the running amount
  8. custom SQL — Allocates a global-surgery-period allowed amount to its post-operative portion: pulls a procedure's POST_OP percentage and GLOB_DAYS (global period length) from Medicare RVU reference data and returns Allowed / GlobalDays * PostOpRate — i.e. a per-day post-op share of the total global allowed amount. — when Modifier 55 is present
  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

Cannot fire (1)

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

Providence-Commercial-Profee · no contract map7 base · 18 adj
no contract map — cannot be resolved
Base terms — first match wins
  1. flat $0 — when NoncoverageStatus Noncovered is present
  2. 110% of Medicare lab (rates as of 2024-01-01)
  3. 125% of Medicare drug
    • CodeRange 90460–90461 → 110%
    • CodeRange 90471–90474 → 110%
    • CodeRange G0008–G0010 → 110%
    • CodeRange 90476–90759 → 110%
  4. 100% of Medicare DME (rates as of 2024-01-01)
  5. 100% of Medicare RVU (rates as of 2024-01-01) — when CodeRange in 70000–79999
  6. 100% of Medicare RVU (rates as of 2024-01-01)
  7. 75% of billed charges
Adjustments — all apply, in order
  1. Medicare multiple-endoscopy reduction
  2. Medicare multiple-radiology reduction — base codes 4
  3. Medicare bilateral-surgery adjustment
  4. Medicare multiple-procedure reduction — base codes 2, 3; pays 100/50%
  5. mid-level provider reduction (by NUCC taxonomy)
  6. modifier 22 present → 135% of the running amount
  7. modifier 54 present → 80% of the running amount
  8. custom SQL — Allocates a global-surgery-period allowed amount to its post-operative portion: pulls a procedure's POST_OP percentage and GLOB_DAYS (global period length) from Medicare RVU reference data and returns Allowed / GlobalDays * PostOpRate — i.e. a per-day post-op share of the total global allowed amount. — when Modifier 55 is present
  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