Customer detail

JewishBoard

28
live contracts
1
cannot fire
15
calc types
5
SQL bodies
3
of those blocked
0
map conflicts

Methodology mix

ModifierAdjustment220
MedicareMultipleProcedureAdjustment27
LesserOfAdjustment16
MedicareMultipleEndoscopyAdjustment16
MedicareMultipleRadiologyAdjustment16
MedicareBilateralSurgeryAdjustment16
ChargeLevelSqlAdjustment16
PercentOfFees14
SqlExpression12
MidLevelProviderAdjustment11
MedicareRVU3
MedicareLab3
MedicareDrug3
MedicareDME3
FlatPercentOfCharges3

Contracts

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

1199SEIU-Profee1 base · 17 adj
1199 SEIU
Profee · all facilities · 2022-02-01 → 2024-12-31
Base terms — first match wins
  1. 100% of the Fixed-Fees-Profee fee schedule
Adjustments — all apply, in order
  1. Medicare multiple-procedure reduction — base codes 2, 3; pays 100/50% — when Modifier 55 is absent
  2. Medicare multiple-endoscopy reduction
  3. Medicare multiple-radiology reduction — base codes 4
  4. Medicare bilateral-surgery adjustment
  5. 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
Aetna-Profee1 base · 18 adj
Aetna
Facility, Profee · all facilities · 2023-08-15 → 2099-12-31
Base terms — first match wins
  1. 100% of the Fixed-Fees-Profee fee schedule
Adjustments — all apply, in order
  1. Medicare multiple-procedure reduction — base codes 2, 3; pays 100/50% — when Modifier 55 is absent
  2. Medicare multiple-endoscopy reduction
  3. Medicare multiple-radiology reduction — base codes 4
  4. Medicare bilateral-surgery adjustment
  5. mid-level provider reduction (by NUCC taxonomy)
  6. modifier 22 present → 135% of the running amount
  7. modifier 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
Anthem-BlueAccess-Profee1 base · 18 adj
Anthem Blue Access
Profee · all facilities · 2023-01-01 → 2099-12-31
Base terms — first match wins
  1. 100% of the Fixed-Fees-Profee fee schedule
Adjustments — all apply, in order
  1. Medicare multiple-procedure reduction — base codes 2, 3; pays 100/50% — when Modifier 55 is absent
  2. Medicare multiple-endoscopy reduction
  3. Medicare multiple-radiology reduction — base codes 4
  4. Medicare bilateral-surgery adjustment
  5. mid-level provider reduction (by NUCC taxonomy)
  6. modifier 22 present → 135% of the running amount
  7. modifier 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
Anthem-Connection-Profee1 base · 18 adj
Anthem Connection
Profee · all facilities · 2023-01-01 → 2999-12-31
Base terms — first match wins
  1. 100% of the Fixed-Fees-Profee fee schedule
Adjustments — all apply, in order
  1. Medicare multiple-procedure reduction — base codes 2, 3; pays 100/50% — when Modifier 55 is absent
  2. Medicare multiple-endoscopy reduction
  3. Medicare multiple-radiology reduction — base codes 4
  4. Medicare bilateral-surgery adjustment
  5. mid-level provider reduction (by NUCC taxonomy)
  6. modifier 22 present → 135% of the running amount
  7. modifier 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
Anthem-Medicaid-Profee1 base · 5 adj
Anthem Medicaid
Facility, Profee · all facilities · 2022-01-01 → 2999-12-31
Base terms — first match wins
  1. custom SQL — APG (Ambulatory Payment Group) rate computation: maps a procedure code to an APG/EAPG code, looks up that APG's relative weight for the service date, looks up a base rate by practice+rate-code+facility-zip+date, and multiplies BaseRate * Weight.
Adjustments — all apply, in order
  1. modifier U4 present → 110% of the running amount
  2. modifier U5 present → 70% of the running amount
  3. Medicare multiple-procedure reduction — base codes 2
  4. modifier 52 present → 50% of the running amount
  5. modifier 73 present → 50% of the running amount
Anthem-Profee1 base · 17 adj
Anthem
Facility, Profee · all facilities · 2023-01-01 → 2099-12-31
Base terms — first match wins
  1. 100% of the Fixed-Fees-Profee fee schedule
Adjustments — all apply, in order
  1. Medicare multiple-procedure reduction — base codes 2, 3; pays 100/50% — when Modifier 55 is absent
  2. Medicare multiple-endoscopy reduction
  3. Medicare multiple-radiology reduction — base codes 4
  4. Medicare bilateral-surgery adjustment
  5. 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
Carelon-BHO1 base · 18 adj
Carelon BHO
Profee · all facilities · 2022-04-01 → 2099-12-31
Base terms — first match wins
  1. 100% of the Fixed-Fees-Profee fee schedule
Adjustments — all apply, in order
  1. Medicare multiple-procedure reduction — base codes 2, 3; pays 100/50% — when Modifier 55 is absent
  2. Medicare multiple-endoscopy reduction
  3. Medicare multiple-radiology reduction — base codes 4
  4. Medicare bilateral-surgery adjustment
  5. mid-level provider reduction (by NUCC taxonomy)
  6. modifier 22 present → 135% of the running amount
  7. modifier 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
Carelon-GHI1 base · 18 adj
Carelon GHI
Facility, Profee · all facilities · 2024-07-01 → 2099-12-31
Base terms — first match wins
  1. 100% of the Fixed-Fees-Profee fee schedule
Adjustments — all apply, in order
  1. Medicare multiple-procedure reduction — base codes 2, 3; pays 100/50% — when Modifier 55 is absent
  2. Medicare multiple-endoscopy reduction
  3. Medicare multiple-radiology reduction — base codes 4
  4. Medicare bilateral-surgery adjustment
  5. mid-level provider reduction (by NUCC taxonomy)
  6. modifier 22 present → 135% of the running amount
  7. modifier 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
Commercial-Payer-Profee1 base · 0 adj
1199 SEIU, Aetna, Anthem, Fidelis, Healthfirst, Magellan Healthcare, NY Hotel Trades, United Healthcare
Profee · all facilities · 2025-01-01 → 2999-12-31
Base terms — first match wins
  1. 100% of the Commercial-Payer-Profee fee schedule
Fidelis-Medicaid-Profee1 base · 5 adj
Fidelis Medicaid
Facility, Profee · all facilities · 2022-01-01 → 2999-12-31
Base terms — first match wins
  1. custom SQL — APG (Ambulatory Payment Group) rate computation: maps a procedure code to an APG/EAPG code, looks up that APG's relative weight for the service date, looks up a base rate by practice+rate-code+facility-zip+date, and multiplies BaseRate * Weight.
Adjustments — all apply, in order
  1. modifier U4 present → 110% of the running amount
  2. modifier U5 present → 70% of the running amount
  3. Medicare multiple-procedure reduction — base codes 2
  4. modifier 52 present → 50% of the running amount
  5. modifier 73 present → 50% of the running amount
Fidelis-Profee1 base · 5 adj
Fidelis
Facility, Profee · all facilities · 2022-01-01 → 2099-12-31
Base terms — first match wins
  1. custom SQL — APG (Ambulatory Payment Group) rate computation: maps a procedure code to an APG/EAPG code, looks up that APG's relative weight for the service date, looks up a base rate by practice+rate-code+facility-zip+date, and multiplies BaseRate * Weight.
Adjustments — all apply, in order
  1. modifier U4 present → 110% of the running amount
  2. modifier U5 present → 70% of the running amount
  3. Medicare multiple-procedure reduction — base codes 2
  4. modifier 52 present → 50% of the running amount
  5. modifier 73 present → 50% of the running amount
HealthFirst-Medicare-Profee1 base · 17 adj
Healthfirst Medicare
Facility, Profee · all facilities · 2022-10-01 → 2999-12-31
Base terms — first match wins
  1. 100% of the Fixed-Fees-Profee fee schedule
Adjustments — all apply, in order
  1. Medicare multiple-procedure reduction — base codes 2, 3; pays 100/50% — when Modifier 55 is absent
  2. Medicare multiple-endoscopy reduction
  3. Medicare multiple-radiology reduction — base codes 4
  4. Medicare bilateral-surgery adjustment
  5. 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
HealthFirst-Profee1 base · 18 adj
Healthfirst
Facility, Profee · all facilities · 2022-10-01 → 2099-12-31
Base terms — first match wins
  1. 100% of the Fixed-Fees-Profee fee schedule
Adjustments — all apply, in order
  1. Medicare multiple-procedure reduction — base codes 2, 3; pays 100/50% — when Modifier 55 is absent
  2. Medicare multiple-endoscopy reduction
  3. Medicare multiple-radiology reduction — base codes 4
  4. Medicare bilateral-surgery adjustment
  5. mid-level provider reduction (by NUCC taxonomy)
  6. modifier 22 present → 135% of the running amount
  7. modifier 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
Healthfirst-Medicaid-Profee1 base · 5 adj
Healthfirst Medicaid
Facility, Profee · all facilities · 2022-01-01 → 2999-12-31
Base terms — first match wins
  1. custom SQL — APG (Ambulatory Payment Group) rate computation: maps a procedure code to an APG/EAPG code, looks up that APG's relative weight for the service date, looks up a base rate by practice+rate-code+facility-zip+date, and multiplies BaseRate * Weight.
Adjustments — all apply, in order
  1. modifier U4 present → 110% of the running amount
  2. modifier U5 present → 70% of the running amount
  3. Medicare multiple-procedure reduction — base codes 2
  4. modifier 52 present → 50% of the running amount
  5. modifier 73 present → 50% of the running amount
Healthfirst-PHSP-Profee1 base · 5 adj
Healthfirst PHSP
Facility, Profee · all facilities · 2022-01-01 → 2999-12-31
Base terms — first match wins
  1. custom SQL — APG (Ambulatory Payment Group) rate computation: maps a procedure code to an APG/EAPG code, looks up that APG's relative weight for the service date, looks up a base rate by practice+rate-code+facility-zip+date, and multiplies BaseRate * Weight.
Adjustments — all apply, in order
  1. modifier U4 present → 110% of the running amount
  2. modifier U5 present → 70% of the running amount
  3. Medicare multiple-procedure reduction — base codes 2
  4. modifier 52 present → 50% of the running amount
  5. modifier 73 present → 50% of the running amount
Magellan-Profee1 base · 17 adj
Magellan Healthcare
Profee · all facilities · 2022-01-01 → 2099-12-31
Base terms — first match wins
  1. 100% of the Fixed-Fees-Profee fee schedule
Adjustments — all apply, in order
  1. Medicare multiple-procedure reduction — base codes 2, 3; pays 100/50% — when Modifier 55 is absent
  2. Medicare multiple-endoscopy reduction
  3. Medicare multiple-radiology reduction — base codes 4
  4. Medicare bilateral-surgery adjustment
  5. 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
Medicaid-Profee1 base · 5 adj
Medicaid
Facility, Profee · all facilities · 2022-01-01 → 2999-12-31
Base terms — first match wins
  1. custom SQL — APG (Ambulatory Payment Group) rate computation: maps a procedure code to an APG/EAPG code, looks up that APG's relative weight for the service date, looks up a base rate by practice+rate-code+facility-zip+date, and multiplies BaseRate * Weight.
Adjustments — all apply, in order
  1. modifier U4 present → 110% of the running amount
  2. modifier U5 present → 70% of the running amount
  3. Medicare multiple-procedure reduction — base codes 2
  4. modifier 52 present → 50% of the running amount
  5. modifier 73 present → 50% of the running amount
Medicare5 base · 18 adj
Medicare
Profee · all facilities · 2023-01-01 → 2999-12-31
Base terms — first match wins
  1. 100% of Medicare lab
  2. 100% of Medicare drug
  3. 100% of Medicare DME
  4. 100% of Medicare RVU
  5. 0% of billed charges
Adjustments — all apply, in order
  1. Medicare multiple-procedure reduction — base codes 2, 3; pays 100/50% — when Modifier 55 is absent
  2. Medicare multiple-endoscopy reduction
  3. Medicare multiple-radiology reduction — base codes 4
  4. Medicare bilateral-surgery adjustment
  5. mid-level provider reduction (by NUCC taxonomy)
  6. modifier 22 present → 135% of the running amount
  7. modifier 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
MetroPlus-Medicaid-EP-1-2-Profee1 base · 5 adj
MetroPlus Medicaid EP 1 & 2
Facility, Profee · all facilities · 2022-01-01 → 2999-12-31
Base terms — first match wins
  1. custom SQL — A NY-Medicaid-style Ambulatory Patient Group (APG) rate: maps the procedure to an EAPG code and weight, looks up a base rate by rate-code+zip+date from a state rate table, multiplies BaseRate*Weight, then applies a flat 120% markup.
Adjustments — all apply, in order
  1. modifier U4 present → 110% of the running amount
  2. modifier U5 present → 70% of the running amount
  3. Medicare multiple-procedure reduction — base codes 2
  4. modifier 52 present → 50% of the running amount
  5. modifier 73 present → 50% of the running amount
MetroPlus-Medicaid-HARP-Profee1 base · 5 adj
MetroPlus Medicaid HARP
Facility, Profee · all facilities · 2022-01-01 → 2999-12-31
Base terms — first match wins
  1. custom SQL — APG (Ambulatory Payment Group) rate computation: maps a procedure code to an APG/EAPG code, looks up that APG's relative weight for the service date, looks up a base rate by practice+rate-code+facility-zip+date, and multiplies BaseRate * Weight.
Adjustments — all apply, in order
  1. modifier U4 present → 110% of the running amount
  2. modifier U5 present → 70% of the running amount
  3. Medicare multiple-procedure reduction — base codes 2
  4. modifier 52 present → 50% of the running amount
  5. modifier 73 present → 50% of the running amount
MetroPlus-Medicare-Profee5 base · 18 adj
MetroPlus, MetroPlus Medicare
Facility, Profee · all facilities · 2022-01-01 → 2999-12-31
Base terms — first match wins
  1. 100% of Medicare lab
  2. 100% of Medicare drug
  3. 100% of Medicare DME
  4. 100% of Medicare RVU
  5. 0% of billed charges
Adjustments — all apply, in order
  1. Medicare multiple-procedure reduction — base codes 2, 3; pays 100/50% — when Modifier 55 is absent
  2. Medicare multiple-endoscopy reduction
  3. Medicare multiple-radiology reduction — base codes 4
  4. Medicare bilateral-surgery adjustment
  5. mid-level provider reduction (by NUCC taxonomy)
  6. modifier 22 present → 135% of the running amount
  7. modifier 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
Molina-Medicaid-EP-Profee1 base · 5 adj
Molina Healthcare EP
Facility, Profee · all facilities · 2022-01-01 → 2999-12-31
Base terms — first match wins
  1. custom SQL — A NY Medicaid APG (Ambulatory Patient Group) rate: maps the procedure to an APG code, looks up that APG's relative weight, multiplies by a zip-code/rate-code-specific base rate, rounds, then applies a flat 20% markup.
Adjustments — all apply, in order
  1. modifier U4 present → 110% of the running amount
  2. modifier U5 present → 70% of the running amount
  3. Medicare multiple-procedure reduction — base codes 2
  4. modifier 52 present → 50% of the running amount
  5. modifier 73 present → 50% of the running amount
Molina-Medicaid-Profee1 base · 5 adj
Molina Healthcare Medicaid
Facility, Profee · all facilities · 2022-01-01 → 2099-12-31
Base terms — first match wins
  1. custom SQL — APG (Ambulatory Payment Group) rate computation: maps a procedure code to an APG/EAPG code, looks up that APG's relative weight for the service date, looks up a base rate by practice+rate-code+facility-zip+date, and multiplies BaseRate * Weight.
Adjustments — all apply, in order
  1. modifier U4 present → 110% of the running amount
  2. modifier U5 present → 70% of the running amount
  3. Medicare multiple-procedure reduction — base codes 2
  4. modifier 52 present → 50% of the running amount
  5. modifier 73 present → 50% of the running amount
NYHotelTrades-Profee1 base · 17 adj
NY Hotel Trades
Profee · all facilities · 2021-07-13 → 2099-12-31
Base terms — first match wins
  1. 100% of the Fixed-Fees-Profee fee schedule
Adjustments — all apply, in order
  1. Medicare multiple-procedure reduction — base codes 2, 3; pays 100/50% — when Modifier 55 is absent
  2. Medicare multiple-endoscopy reduction
  3. Medicare multiple-radiology reduction — base codes 4
  4. Medicare bilateral-surgery adjustment
  5. 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
United-Healthcare-Medicaid-Profee1 base · 5 adj
United Healthcare Medicaid
Facility, Profee · all facilities · 2023-01-01 → 2099-12-31
Base terms — first match wins
  1. custom SQL — APG (Ambulatory Payment Group) rate computation: maps a procedure code to an APG/EAPG code, looks up that APG's relative weight for the service date, looks up a base rate by practice+rate-code+facility-zip+date, and multiplies BaseRate * Weight.
Adjustments — all apply, in order
  1. modifier U4 present → 110% of the running amount
  2. modifier U5 present → 70% of the running amount
  3. Medicare multiple-procedure reduction — base codes 2
  4. modifier 52 present → 50% of the running amount
  5. modifier 73 present → 50% of the running amount
UnitedHealthcare-Medicare-Profee1 base · 18 adj
United Healthcare Medicare
Profee · all facilities · 2023-04-01 → 2999-12-31
Base terms — first match wins
  1. 100% of the Fixed-Fees-Profee fee schedule
Adjustments — all apply, in order
  1. Medicare multiple-procedure reduction — base codes 2, 3; pays 100/50% — when Modifier 55 is absent
  2. Medicare multiple-endoscopy reduction
  3. Medicare multiple-radiology reduction — base codes 4
  4. Medicare bilateral-surgery adjustment
  5. mid-level provider reduction (by NUCC taxonomy)
  6. modifier 22 present → 135% of the running amount
  7. modifier 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
UnitedHealthcare-Profee1 base · 18 adj
United Healthcare
Profee · all facilities · 2023-08-15 → 2099-12-31
Base terms — first match wins
  1. 100% of the Fixed-Fees-Profee fee schedule
Adjustments — all apply, in order
  1. Medicare multiple-procedure reduction — base codes 2, 3; pays 100/50% — when Modifier 55 is absent
  2. Medicare multiple-endoscopy reduction
  3. Medicare multiple-radiology reduction — base codes 4
  4. Medicare bilateral-surgery adjustment
  5. mid-level provider reduction (by NUCC taxonomy)
  6. modifier 22 present → 135% of the running amount
  7. modifier 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
Wellcare Medicare5 base · 18 adj
Wellcare Medicare
Profee · all facilities · 2025-09-01 → 2999-12-31
Base terms — first match wins
  1. 90% of Medicare lab
  2. 90% of Medicare drug
  3. 90% of Medicare DME
  4. 90% of Medicare RVU
  5. 0% of billed charges
Adjustments — all apply, in order
  1. Medicare multiple-procedure reduction — base codes 2, 3; pays 100/50% — when Modifier 55 is absent
  2. Medicare multiple-endoscopy reduction
  3. Medicare multiple-radiology reduction — base codes 4
  4. Medicare bilateral-surgery adjustment
  5. mid-level provider reduction (by NUCC taxonomy)
  6. modifier 22 present → 135% of the running amount
  7. modifier 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.

Charges · contract map selects nothing1 base · 0 adj
— no insurance selected —
— no bill type selected — · — nothing selected — · 2025-06-23 → 2999-12-31
Base terms — first match wins
  1. custom SQL — Nothing — the SQL body is only the standard input/output comment scaffold with no executable statement, so this SqlExpression always yields an empty/null result.