Customer detail

MiddletownMedical

22
live contracts
6
cannot fire
18
calc types
1
SQL bodies
0
of those blocked
0
map conflicts

Methodology mix

MidLevelProviderAdjustment68
PercentOfFees60
ModifierAdjustment57
MedicareRVU36
MedicareMultipleProcedureAdjustment33
LesserOfAdjustment28
MedicareBilateralSurgeryAdjustment28
MedicareDrug25
MedicareLab23
MedicareMultipleRadiologyAdjustment22
FlatPercentOfCharges21
FlatFee20
MedicareDME19
CalculationBuilder16
MedicareMultipleTherapyAdjustment12
MedicareMultipleEndoscopyAdjustment4
ChargeLevelSqlAdjustment2
MultipleProcedureAdjustment1

Contracts

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

Aetna-Profee-Clinic10 base · 17 adj
Aetna
Profee · all facilities · 2024-12-01 → 2025-11-30
Base terms — first match wins
  1. 100% of the Aetna-UrgentCare-Profee-Clinic fee schedule — when PlaceOfService 20 is present
  2. 0% of billed charges — when PlaceOfService 20 is present
  3. 100% of the Aetna-Profee-Clinic-OfficeServices-Fees fee schedule — when FacilityType in Clinic
  4. 104% of Medicare lab (NY, rates as of 2023-01-01) ⚠︎ named “100% of 2023 Medicare Lab Fees” but configured at 104%
  5. 104% of Medicare RVU (rates as of 2023-01-01) — when FacilityType in Clinic, Urgent Care Facility
    • CodeRange 43240–43250 → 128%
    • CodeRange 45386–49501 → 128%
    • CodeRange 45379–45379 → 128%
    • CodeRange 99202–99384 → 130%
    • CodeRange 99391–99499 → 130%
    • CodeRange 70010–79999 → 125%
  6. 104% of the Vaccine-Profee-Clinic fee schedule
  7. 104% of Medicare drug (rates as of 2023-01-01) ⚠︎ named “100% of 2023 Medicare Drug” but configured at 104%
  8. 104% of the Aetna-COVIDcodes-Profee-Clinic fee schedule
  9. 104% of Medicare RVU (rates as of 2023-01-01)
  10. 0% of billed charges
Adjustments — all apply, in order
  1. multiple-procedure reduction (contract rules) — base codes 0, 1, 2, 3, 4, 5, 6, 7, 8, 9; pays 100/0%
  2. Medicare multiple-endoscopy reduction
  3. Medicare multiple-therapy reduction (MPPR) — base codes 5; pays 100/50%
  4. Medicare multiple-radiology reduction — base codes 4
  5. Medicare bilateral-surgery adjustment
  6. Medicare multiple-procedure reduction — base codes 0, 1, 2, 3, 4, 5, 6, 7, 8, 9; pays 100/0% — when ProcedureCode 64636 is present
  7. Medicare multiple-procedure reduction — base codes 2, 3; pays 100/50/50/50/50%
  8. mid-level provider reduction (by NUCC taxonomy) — when CodeRange in 10000–69990
  9. mid-level provider reduction (by NUCC taxonomy) — when CodeRange in 70010–79999
  10. mid-level provider reduction (by NUCC taxonomy) — when CodeRange in 90281–98999
  11. mid-level provider reduction (by NUCC taxonomy) — when CodeRange in 99091–99499
  12. modifier CQ present → 85% of the running amount
  13. modifier 22 present → 135% of the running amount
  14. modifier 62 present → 62.5% of the running amount
  15. modifier 78 present → 70% of the running amount
  16. modifier 80 present → 16% of the running amount
  17. cap each charge and the account total at 100% of billed charges
Aetna-Profee-Clinic-202510 base · 17 adj
Aetna
Profee · all facilities · 2025-12-01 → 2999-12-31
Base terms — first match wins
  1. 100% of the Aetna-UrgentCare-Profee-Clinic fee schedule — when PlaceOfService 20 is present
  2. 0% of billed charges — when PlaceOfService 20 is present
  3. 100% of the Aetna-Profee-Clinic-OfficeServices-Fees fee schedule — when FacilityType in Clinic
  4. 108% of the Aetna-COVIDcodes-Profee-Clinic fee schedule
  5. 108% of Medicare lab (NY) ⚠︎ named “100% of 2023 Medicare Lab Fees” but configured at 108%
  6. 108% of Medicare drug (rates as of 2023-01-01) ⚠︎ named “100% of 2023 Medicare Drug” but configured at 108%
  7. 108% of the Vaccine-Profee-Clinic fee schedule
  8. 108% of Medicare RVU (rates as of 2023-01-01) — when FacilityType in Clinic, Urgent Care Facility
    • CodeRange 43240–43250 → 133%
    • CodeRange 45386–49501 → 133%
    • CodeRange 45379–45379 → 133%
    • CodeRange 99202–99384 → 135%
    • CodeRange 99391–99499 → 135%
    • CodeRange 70010–79999 → 130%
  9. 108% of Medicare RVU (rates as of 2023-01-01) — when FacilityType in ASC, Hospital, Urgent Care Facility
  10. 0% of billed charges
Adjustments — all apply, in order
  1. Medicare multiple-radiology reduction — base codes 4
  2. Medicare multiple-endoscopy reduction
  3. Medicare multiple-therapy reduction (MPPR) — base codes 5; pays 100/50%
  4. Medicare bilateral-surgery adjustment
  5. Medicare multiple-procedure reduction — base codes 0, 1, 2, 3, 4, 5, 6, 7, 8, 9; pays 100/50/50/50/50% — when ProcedureCode 64636 is present
  6. Medicare multiple-procedure reduction — base codes 2, 3; pays 100/50/50/50/50%
  7. mid-level provider reduction (by NUCC taxonomy) — when CodeRange in 10000–69990
  8. mid-level provider reduction (by NUCC taxonomy) — when CodeRange in 70010–79999
  9. mid-level provider reduction (by NUCC taxonomy) — when CodeRange in 90281–98999
  10. mid-level provider reduction (by NUCC taxonomy) — when CodeRange in 99091–99499
  11. modifier 52 present → 50% of the running amount
  12. modifier CQ present → 85% of the running amount
  13. modifier 22 present → 135% of the running amount
  14. modifier 62 present → 62.5% of the running amount
  15. modifier 78 present → 70% of the running amount
  16. modifier 80 present → 16% of the running amount
  17. cap each charge and the account total at 100% of billed charges
Anthem-BlueAccess-Profee-Clinic7 base · 9 adj
Anthem Blue Access
Profee · all facilities · 2026-04-01 → 2999-12-31
Base terms — first match wins
  1. flat $0 — when CodeRange in G2211–G2211
  2. 80% of the Aetna-Profee-Clinic-OfficeServices-Fees fee schedule
  3. 83% of the Anthem-POL-Profee-Fees fee schedule
  4. 0% of Medicare lab (NY, rates as of 2024-04-01)
  5. 83% of Medicare DME (NY, rates as of 2024-04-01)
  6. 100% of Medicare drug (rates as of 2024-04-01)
  7. 83% of Medicare RVU (rates as of 2024-04-01)
    • CodeRange 99201–99999 → 110%
    • CodeRange 70000–79999 → 104%
    • CodeRange 30000–39999 → 104%
Adjustments — all apply, in order
  1. Medicare multiple-radiology reduction — base codes 4
  2. Medicare multiple-therapy reduction (MPPR) — base codes 5; pays 100/50%
  3. Medicare bilateral-surgery adjustment
  4. Medicare multiple-procedure reduction — base codes 2, 3; pays 100/50/50/50/50/50%
  5. mid-level provider reduction (by NUCC taxonomy) — when CodeRange in 10021–69990
  6. mid-level provider reduction (by NUCC taxonomy) — when CodeRange in 70010–79999
  7. mid-level provider reduction (by NUCC taxonomy) — when CodeRange in 90281–98999
  8. mid-level provider reduction (by NUCC taxonomy) — when CodeRange in 99091–99499
  9. cap each charge and the account total at 100% of billed charges
Anthem-BlueAccess-Profee-Clinic8 base · 9 adj
Anthem Blue Access
Profee · all facilities · 2025-04-01 → 2026-03-31
Base terms — first match wins
  1. flat $0 — when CodeRange in G2211–G2211
  2. 80% of the Aetna-Profee-Clinic-OfficeServices-Fees fee schedule
  3. 82% of the Anthem-POL-Profee-Fees fee schedule
  4. 0% of Medicare lab (NY, rates as of 2025-04-01)
  5. 100% of Medicare drug (rates as of 2024-04-01)
  6. 82% of Medicare DME (NY, rates as of 2024-04-01)
  7. 82% of Medicare RVU (rates as of 2024-04-01)
    • CodeRange 99201–99999 → 108%
    • CodeRange 70000–79999 → 102%
    • CodeRange 30000–39999 → 102%
  8. 0% of billed charges
Adjustments — all apply, in order
  1. Medicare multiple-radiology reduction — base codes 4
  2. Medicare multiple-therapy reduction (MPPR) — base codes 5; pays 100/50%
  3. Medicare bilateral-surgery adjustment
  4. Medicare multiple-procedure reduction — base codes 2, 3; pays 100/50/50/50/50/50%
  5. mid-level provider reduction (by NUCC taxonomy) — when CodeRange in 10021–69990
  6. mid-level provider reduction (by NUCC taxonomy) — when CodeRange in 70010–79999
  7. mid-level provider reduction (by NUCC taxonomy) — when CodeRange in 90281–98999
  8. mid-level provider reduction (by NUCC taxonomy) — when CodeRange in 99091–99499
  9. cap each charge and the account total at 100% of billed charges
Anthem-BlueAccess-Profee-Clinic8 base · 9 adj
Anthem Blue Access
Profee · all facilities · 2024-04-01 → 2025-03-31
Base terms — first match wins
  1. flat $0 — when CodeRange in G2211–G2211
  2. 80% of the Aetna-Profee-Clinic-OfficeServices-Fees fee schedule
  3. 80% of the Anthem-POL-Profee-Fees fee schedule
  4. 0% of Medicare lab (NY, rates as of 2024-04-01)
  5. 80% of Medicare DME (NY, rates as of 2024-04-01)
  6. 100% of Medicare drug (rates as of 2024-04-01)
  7. 80% of Medicare RVU (rates as of 2024-04-01)
    • CodeRange 99201–99999 → 106%
    • CodeRange 70000–79999 → 100%
    • CodeRange 30000–39999 → 100%
  8. 0% of billed charges
Adjustments — all apply, in order
  1. Medicare multiple-radiology reduction — base codes 4
  2. Medicare multiple-therapy reduction (MPPR) — base codes 5; pays 100/50%
  3. Medicare bilateral-surgery adjustment
  4. Medicare multiple-procedure reduction — base codes 2, 3; pays 100/50/50/50/50/50%
  5. mid-level provider reduction (by NUCC taxonomy) — when CodeRange in 10021–69990
  6. mid-level provider reduction (by NUCC taxonomy) — when CodeRange in 70010–79999
  7. mid-level provider reduction (by NUCC taxonomy) — when CodeRange in 90281–98999
  8. mid-level provider reduction (by NUCC taxonomy) — when CodeRange in 99091–99499
  9. cap each charge and the account total at 100% of billed charges
Anthem-Medicaid-Profee-Clinic5 base · 8 adj
Anthem Medicaid
Profee · all facilities · 2025-01-01 → 2999-12-31
Base terms — first match wins
  1. 90% of Medicare lab (NY, rates as of 2024-04-01)
  2. 90% of Medicare DME (NY, rates as of 2024-04-01)
  3. 90% of Medicare drug (rates as of 2024-04-01)
  4. 90% of Medicare RVU (rates as of 2024-04-01)
  5. 0% of billed charges
Adjustments — all apply, in order
  1. Medicare multiple-radiology reduction — base codes 4
  2. Medicare bilateral-surgery adjustment
  3. Medicare multiple-procedure reduction — base codes 2, 3; pays 100/50/50/50/50/50%
  4. mid-level provider reduction (by NUCC taxonomy) — when CodeRange in 10021–69990
  5. mid-level provider reduction (by NUCC taxonomy) — when CodeRange in 70010–79999
  6. mid-level provider reduction (by NUCC taxonomy) — when CodeRange in 90281–98999
  7. mid-level provider reduction (by NUCC taxonomy) — when CodeRange in 99091–99499
  8. cap each charge and the account total at 100% of billed charges
Anthem-Medicare-Profee4 base · 6 adj
Anthem Medicare
Profee · all facilities · 2024-01-01 → 2999-12-31
Base terms — first match wins
  1. 100% of Medicare DME (NY)
  2. 100% of Medicare drug
  3. 100% of Medicare lab (NY)
  4. 100% of Medicare RVU
Adjustments — all apply, in order
  1. Medicare multiple-procedure reduction — base codes 2
  2. Medicare bilateral-surgery adjustment
  3. mid-level provider reduction (by NUCC taxonomy)
  4. Medicare multiple-radiology reduction — base codes 4
  5. Medicare multiple-therapy reduction (MPPR) — base codes 5; pays 100/50%
  6. cap the account total at 100% of billed charges
Anthem-PPO/EPO/HMO/POS/Indemnity-Profee-Clinic9 base · 9 adj
Anthem
Profee · all facilities · 2024-04-01 → 2025-03-31
Base terms — first match wins
  1. flat $0 — when CodeRange in G2211–G2211
  2. 100% of the Anthem-PPO/EPO/HMO/POS/Indemnity-Profee-Clinic-SuiteFeeAddon-Fees fee schedule
  3. 100% of the Aetna-Profee-Clinic-OfficeServices-Fees fee schedule
  4. 100% of the Anthem-POL-Profee-Fees fee schedule
  5. 0% of Medicare lab (NY, rates as of 2024-04-01)
  6. 100% of Medicare DME (NY, rates as of 2024-04-01)
  7. 100% of Medicare drug (rates as of 2024-04-01)
  8. 100% of Medicare RVU (rates as of 2024-04-01)
    • CodeRange 99201–99999 → 132%
    • CodeRange 70000–79999 → 120%
    • CodeRange 30000–39999 → 120%
  9. 0% of billed charges
Adjustments — all apply, in order
  1. Medicare multiple-radiology reduction — base codes 4
  2. Medicare multiple-therapy reduction (MPPR) — base codes 5; pays 100/50%
  3. Medicare bilateral-surgery adjustment
  4. Medicare multiple-procedure reduction — base codes 2, 3; pays 100/50/50/50/50/50%
  5. mid-level provider reduction (by NUCC taxonomy) — when CodeRange in 10021–69990
  6. mid-level provider reduction (by NUCC taxonomy) — when CodeRange in 70010–79999
  7. mid-level provider reduction (by NUCC taxonomy) — when CodeRange in 90281–98999
  8. mid-level provider reduction (by NUCC taxonomy) — when CodeRange in 99091–99499
  9. cap each charge and the account total at 100% of billed charges
Anthem-PPO/EPO/HMO/POS/Indemnity-Profee-Clinic9 base · 10 adj
Anthem
Profee · all facilities · 2025-04-01 → 2026-03-31
Base terms — first match wins
  1. flat $0 — when CodeRange in G2211–G2211
  2. 100% of the Anthem-PPO/EPO/HMO/POS/Indemnity-Profee-Clinic-SuiteFeeAddon-Fees fee schedule
  3. 100% of the Aetna-Profee-Clinic-OfficeServices-Fees fee schedule
  4. 102% of the Anthem-POL-Profee-Fees fee schedule
  5. 0% of Medicare lab (NY, rates as of 2025-04-01)
  6. 100% of Medicare drug (rates as of 2024-04-01)
  7. 102% of Medicare DME (NY, rates as of 2024-04-01)
  8. 102% of Medicare RVU (rates as of 2024-04-01)
    • CodeRange 99201–99999 → 135%
    • CodeRange 70000–79999 → 122%
    • CodeRange 30000–39999 → 122%
  9. 0% of billed charges
Adjustments — all apply, in order
  1. Medicare bilateral-surgery adjustment
  2. Medicare multiple-radiology reduction — base codes 4
  3. Medicare multiple-therapy reduction (MPPR) — base codes 5; pays 100/50%
  4. Medicare multiple-procedure reduction — base codes 2, 3; pays 100/50/50/50/50/50%
  5. mid-level provider reduction (by NUCC taxonomy) — when CodeRange in 10021–69990
  6. mid-level provider reduction (by NUCC taxonomy) — when CodeRange in 70010–79999
  7. mid-level provider reduction (by NUCC taxonomy) — when CodeRange in 90281–98999
  8. mid-level provider reduction (by NUCC taxonomy) — when CodeRange in 99091–99499
  9. modifier 52 present → 50% of the running amount
  10. cap each charge and the account total at 100% of billed charges
Anthem-PPO/EPO/HMO/POS/Indemnity-Profee-Clinic8 base · 9 adj
Anthem
Profee · all facilities · 2026-04-01 → 2999-12-31
Base terms — first match wins
  1. flat $0 — when CodeRange in G2211–G2211
  2. 100% of the Aetna-Profee-Clinic-OfficeServices-Fees fee schedule
  3. 100% of the Anthem-PPO/EPO/HMO/POS/Indemnity-Profee-Clinic-SuiteFeeAddon-Fees fee schedule
  4. 104% of the Anthem-POL-Profee-Fees fee schedule
  5. 0% of Medicare lab (NY, rates as of 2024-04-01)
  6. 104% of Medicare DME (NY, rates as of 2024-04-01)
  7. 100% of Medicare drug (rates as of 2024-04-01)
  8. 104% of Medicare RVU (rates as of 2024-04-01)
    • CodeRange 99201–99999 → 137%
    • CodeRange 70000–79999 → 125%
    • CodeRange 30000–39999 → 125%
Adjustments — all apply, in order
  1. Medicare multiple-radiology reduction — base codes 4
  2. Medicare multiple-therapy reduction (MPPR) — base codes 5; pays 100/50%
  3. Medicare bilateral-surgery adjustment
  4. Medicare multiple-procedure reduction — base codes 2, 3; pays 100/50/50/50/50/50%
  5. mid-level provider reduction (by NUCC taxonomy) — when CodeRange in 10021–69990
  6. mid-level provider reduction (by NUCC taxonomy) — when CodeRange in 70010–79999
  7. mid-level provider reduction (by NUCC taxonomy) — when CodeRange in 90281–98999
  8. mid-level provider reduction (by NUCC taxonomy) — when CodeRange in 99091–99499
  9. cap each charge and the account total at 100% of billed charges
Emblem-Medicaid-Profee-Clinic5 base · 8 adj
Emblem Medicaid
Profee · all facilities · 2025-01-01 → 2999-12-31
Base terms — first match wins
  1. flat $0 — when CodeRange in G2211–G2211
  2. flat $500 — when CodeRange in A4550–A4550
  3. 70% of Medicare lab (NY)
  4. 95% of Medicare RVU
  5. 45% of billed charges
Adjustments — all apply, in order
  1. Medicare multiple-radiology reduction — base codes 4
  2. Medicare bilateral-surgery adjustment
  3. Medicare multiple-procedure reduction — base codes 2, 3; pays 100/50/50/50/50/50%
  4. mid-level provider reduction (by NUCC taxonomy) — when CodeRange in 10021–69990
  5. mid-level provider reduction (by NUCC taxonomy) — when CodeRange in 70010–79999
  6. mid-level provider reduction (by NUCC taxonomy) — when CodeRange in 90281–98999
  7. mid-level provider reduction (by NUCC taxonomy) — when CodeRange in 99091–99499
  8. cap each charge and the account total at 100% of billed charges
Emblem-Medicare-Profee-Clinic5 base · 8 adj
Emblem Medicare
Profee · all facilities · 2025-01-01 → 2999-12-31
Base terms — first match wins
  1. flat $0 — when CodeRange in G2211–G2211
  2. flat $500 — when CodeRange in A4550–A4550
  3. 70% of Medicare lab (NY)
  4. 100% of Medicare RVU
  5. 45% of billed charges
Adjustments — all apply, in order
  1. Medicare multiple-radiology reduction — base codes 4
  2. Medicare bilateral-surgery adjustment
  3. Medicare multiple-procedure reduction — base codes 2, 3; pays 100/50/50/50/50/50%
  4. mid-level provider reduction (by NUCC taxonomy) — when CodeRange in 10021–69990
  5. mid-level provider reduction (by NUCC taxonomy) — when CodeRange in 70010–79999
  6. mid-level provider reduction (by NUCC taxonomy) — when CodeRange in 90281–98999
  7. mid-level provider reduction (by NUCC taxonomy) — when CodeRange in 99091–99499
  8. cap each charge and the account total at 100% of billed charges
Emblem-PPO-Profee-Clinic5 base · 9 adj
Emblem
Profee · all facilities · 2025-01-01 → 2999-12-31
Base terms — first match wins
  1. flat $0 — when CodeRange in G2211–G2211
  2. flat $500 — when CodeRange in A4550–A4550
  3. 70% of the Emblem-POL-Profee-Fees fee schedule
  4. 143% of Medicare RVU
    • CodeRange 96360–96549 → 222%
    • CodeRange 64491–64495 → 140%
    • CodeRange 36245–36245 → 140%
    • CodeRange 36248–36248 → 140%
    • CodeRange 36470–36475 → 140%
    • CodeRange 37220–37229 → 140%
    • CodeRange 37234–37234 → 140%
    • CodeRange 36140–36140 → 140%
    • CodeRange 43217–43217 → 140%
    • CodeRange 43235–43239 → 140%
    • CodeRange 43245–43249 → 140%
    • CodeRange 43262–43264 → 140%
    • CodeRange 43275–43275 → 140%
    • CodeRange 45331–45331 → 140%
    • CodeRange 45380–45385 → 140%
    • CodeRange 45390–45390 → 140%
    • CodeRange 56501–56501 → 140%
    • CodeRange 57250–57250 → 140%
    • CodeRange 58300–58301 → 140%
    • CodeRange 64483–64483 → 140%
    • CodeRange 80000–89999 → 70%
    • CodeRange 75630–75630 → 140%
    • CodeRange 75710–75716 → 140%
    • CodeRange 75774–75774 → 140%
    • CodeRange 76942–76942 → 140%
    • CodeRange 37252–37253 → 140%
  5. 45% of billed charges
Adjustments — all apply, in order
  1. Medicare multiple-radiology reduction — base codes 4
  2. Medicare multiple-therapy reduction (MPPR) — base codes 5; pays 100/50%
  3. Medicare bilateral-surgery adjustment
  4. Medicare multiple-procedure reduction — base codes 2, 3; pays 100/50/50/50/50/50%
  5. mid-level provider reduction (by NUCC taxonomy) — when CodeRange in 10000–69990
  6. mid-level provider reduction (by NUCC taxonomy) — when CodeRange in 70010–79999
  7. mid-level provider reduction (by NUCC taxonomy) — when CodeRange in 90281–98999
  8. mid-level provider reduction (by NUCC taxonomy) — when CodeRange in 99091–99499
  9. cap each charge and the account total at 100% of billed charges
Empire-Profee-Clinic17 base · 8 adj
Empire
Profee · Clinic, Urgent Care Facility · 2023-05-01 → 2999-12-31
Base terms — first match wins
  1. flat $0 — when CodeRange in G2211–G2211
  2. 100% of the Empire-Profee-Clinic-Carveout-Fees fee schedule
  3. 100% of the Empire-Profee-Clinic-NonFacilityFees fee schedule — when FacilityType in Clinic
  4. computed expression (operands follow)
  5. 100% of the Empire-Multiplier-Rates fee schedule
  6. Multiply 100% of Medicare drug
  7. computed expression (operands follow)
  8. 100% of the Empire-Multiplier-Rates fee schedule
  9. Multiply 100% of Medicare DME (NY)
  10. computed expression (operands follow)
  11. 100% of the Empire-Multiplier-Rates fee schedule
  12. Multiply 100% of Medicare lab (rates as of 2020-02-01)
  13. computed expression (operands follow)
  14. 100% of the Empire-Multiplier-Rates fee schedule
  15. Multiply 100% of Medicare RVU (rates as of 2020-02-01)
  16. 100% of Medicare drug
  17. 40% of billed charges
Adjustments — all apply, in order
  1. Medicare multiple-radiology reduction — base codes 4
  2. mid-level provider reduction (by NUCC taxonomy)
  3. Medicare bilateral-surgery adjustment
  4. Medicare multiple-procedure reduction — base codes 2, 3; pays 100/50/50/50/50/50%
  5. modifier CQ present → 85% of the running amount
  6. modifier 52 present → 50% of the running amount
  7. modifier 53 present → 25% of the running amount
  8. cap each charge and the account total at 100% of billed charges
Empire-Profee-Facility16 base · 8 adj
Empire
Profee · ASC, Hospital · 2023-05-01 → 2999-12-31
Base terms — first match wins
  1. flat $0 — when CodeRange in G2211–G2211
  2. 100% of the Empire-Profee-Clinic-Carveout-Fees fee schedule
  3. computed expression (operands follow)
  4. 100% of the Empire-Multiplier-Rates fee schedule
  5. Multiply 100% of Medicare drug
  6. computed expression (operands follow)
  7. 100% of the Empire-Multiplier-Rates fee schedule
  8. Multiply 100% of Medicare DME (NY)
  9. computed expression (operands follow)
  10. 100% of the Empire-Multiplier-Rates fee schedule
  11. Multiply 100% of Medicare lab (rates as of 2020-02-01)
  12. computed expression (operands follow)
  13. 100% of the Empire-Multiplier-Rates fee schedule
  14. Multiply 100% of Medicare RVU (rates as of 2020-02-01)
  15. 100% of Medicare drug
  16. 40% of billed charges
Adjustments — all apply, in order
  1. mid-level provider reduction (by NUCC taxonomy)
  2. Medicare multiple-radiology reduction — base codes 4
  3. Medicare bilateral-surgery adjustment
  4. Medicare multiple-procedure reduction — base codes 2, 3; pays 100/50/50/50/50/50%
  5. modifier CQ present → 85% of the running amount
  6. cap each charge and the account total at 100% of billed charges
  7. modifier 52 present → 52% of the running amount
  8. modifier 53 present → 50% of the running amount
MVP-Comm-Profee-Clinic11 base · 7 adj
MVP
Profee · all facilities · 2025-01-01 → 2025-12-31
Base terms — first match wins
  1. 165% of Medicare RVU (rates as of 2025-01-01) — when PlaceOfService 20 is present; CodeRange in 99211–99215
  2. flat $27 — when PlaceOfService 20 is present; CodeRange in 99053–99053
  3. 100% of the MVP-TherapyCodes-Profee-Fees fee schedule — when ProviderType in Physical Therapist
  4. 100% of the MVP-TherapyCodes-Followup--Profee-Fees fee schedule — when ProviderType in Physical Therapist
  5. 100% of Medicare DME (NY, rates as of 2025-01-01)
  6. 106% of Medicare drug (rates as of 2025-01-01)
    • CodeRange J9000–J9999 → 112%
  7. 100% of Medicare lab (rates as of 2025-01-01)
  8. 163.2% of Medicare RVU (rates as of 2025-01-01) — when ProviderType in Orthopedic Surgery; CodeRange in 20100–29999
  9. 200% of Medicare RVU (rates as of 2025-01-01) — when CodeRange in 96360–96549
  10. 153% of Medicare RVU (rates as of 2025-01-01) — when PlaceOfService 11 is present
    • CodeRange 70551–70553 → 205%
    • CodeRange 72141–72149 → 205%
    • CodeRange 70554–72140 → 175%
    • CodeRange 95800–95811 → 155%
    • CodeRange 33285–33285 → 161%
    • CodeRange 36140–36140 → 161%
    • CodeRange 36245–36248 → 161%
    • CodeRange 36470–36471 → 161%
    • CodeRange 36475–36475 → 161%
    • CodeRange 37220–37220 → 161%
    • CodeRange 37223–37223 → 161%
    • CodeRange 70010–70550 → 175%
    • CodeRange 37234–37234 → 161%
    • CodeRange 37252–37253 → 161%
    • CodeRange 56441–56441 → 161%
    • CodeRange 56501–56501 → 161%
    • CodeRange 57250–57250 → 161%
    • CodeRange 57520–57520 → 161%
    • CodeRange 64483–64483 → 161%
    • CodeRange 64491–64492 → 161%
    • CodeRange 64493–64495 → 161%
    • CodeRange 93015–93016 → 175%
    • CodeRange 93018–93018 → 175%
    • CodeRange 37765–37766 → 175%
    • CodeRange 96372–96372 → 100%
    • CodeRange 96374–96376 → 100%
    • CodeRange 96365–96368 → 100%
    • CodeRange 96409–96409 → 100%
    • CodeRange 96411–96411 → 100%
    • CodeRange 96413–96417 → 100%
    • CodeRange 96360–96361 → 100%
    • CodeRange 90460–90461 → 100%
    • CodeRange 90473–90474 → 100%
    • CodeRange 74184–79999 → 175%
    • CodeRange 72150–72194 → 175%
    • CodeRange 72195–72197 → 205%
    • CodeRange 72198–73220 → 175%
    • CodeRange 73221–73221 → 205%
    • CodeRange 73222–73719 → 175%
    • CodeRange 73720–73721 → 205%
    • CodeRange 73722–74181 → 175%
    • CodeRange 74182–74183 → 205%
    • CodeRange 37227–37227 → 161%
  11. 153% of Medicare RVU (rates as of 2025-01-01)
    • CodeRange 70551–70553 → 205%
    • CodeRange 73221–73221 → 205%
    • CodeRange 70554–72140 → 175%
    • CodeRange 95800–95811 → 155%
    • CodeRange 36470–36471 → 175%
    • CodeRange 36475–36475 → 175%
    • CodeRange 93015–93016 → 175%
    • CodeRange 70010–70550 → 175%
    • CodeRange 37765–37766 → 175%
    • CodeRange 96372–96372 → 100%
    • CodeRange 96374–96376 → 100%
    • CodeRange 96365–96368 → 100%
    • CodeRange 96409–96409 → 100%
    • CodeRange 96411–96411 → 100%
    • CodeRange 96413–96417 → 100%
    • CodeRange 96360–96361 → 100%
    • CodeRange 90460–90461 → 100%
    • CodeRange 90473–90474 → 100%
    • CodeRange 72141–72149 → 205%
    • CodeRange 72150–72194 → 175%
    • CodeRange 72195–72197 → 205%
    • CodeRange 72198–73220 → 175%
    • CodeRange 74184–79999 → 175%
    • CodeRange 73222–73719 → 175%
    • CodeRange 73720–73721 → 205%
    • CodeRange 73722–74181 → 175%
    • CodeRange 74182–74183 → 205%
    • CodeRange 93018–93018 → 175%
Adjustments — all apply, in order
  1. Medicare multiple-procedure reduction — base codes 2
  2. Medicare bilateral-surgery adjustment
  3. mid-level provider reduction (by NUCC taxonomy)
  4. Medicare multiple-procedure reduction — base codes 5; pays 100/0%
  5. modifier CQ present → 85% of the running amount
  6. modifier 52 present → 50% of the running amount
  7. cap the account total at 100% of billed charges
MVP-Comm-Profee-Clinic12 base · 6 adj
MVP
Profee · all facilities · 2026-01-01 → 2999-12-31
Base terms — first match wins
  1. 165% of Medicare RVU (rates as of 2025-01-01) — when PlaceOfService 20 is present; CodeRange in 99211–99215
  2. flat $27 — when PlaceOfService 20 is present; CodeRange in 99053–99053
  3. 100% of the MVP-TherapyCodes-Profee-Fees fee schedule — when ProviderType in Physical Therapist
  4. 100% of the MVP-TherapyCodes-Followup--Profee-Fees fee schedule — when ProviderType in Physical Therapist
  5. 100% of Medicare DME (NY, rates as of 2025-01-01)
  6. 106% of Medicare drug (rates as of 2025-01-01)
    • CodeRange J9000–J9999 → 112%
  7. 100% of Medicare lab (rates as of 2025-01-01)
  8. 163.2% of Medicare RVU (rates as of 2025-01-01) — when ProviderType in Orthopedic Surgery; CodeRange in 20100–29999
  9. 200% of Medicare RVU (rates as of 2025-01-01) — when CodeRange in 96360–96549
  10. 153% of Medicare RVU (rates as of 2025-01-01) — when PlaceOfService 11 is present
    • CodeRange 70551–70553 → 205%
    • CodeRange 72141–72149 → 205%
    • CodeRange 70554–72140 → 175%
    • CodeRange 95800–95811 → 155%
    • CodeRange 33285–33285 → 161%
    • CodeRange 36140–36140 → 161%
    • CodeRange 36245–36248 → 161%
    • CodeRange 36470–36471 → 161%
    • CodeRange 36475–36475 → 161%
    • CodeRange 37220–37220 → 161%
    • CodeRange 37223–37223 → 161%
    • CodeRange 70010–70550 → 175%
    • CodeRange 37234–37234 → 161%
    • CodeRange 37252–37253 → 161%
    • CodeRange 56441–56441 → 161%
    • CodeRange 56501–56501 → 161%
    • CodeRange 57250–57250 → 161%
    • CodeRange 57520–57520 → 161%
    • CodeRange 64483–64483 → 161%
    • CodeRange 64491–64492 → 161%
    • CodeRange 64493–64495 → 161%
    • CodeRange 93015–93016 → 175%
    • CodeRange 93018–93018 → 175%
    • CodeRange 37765–37766 → 175%
    • CodeRange 96372–96372 → 100%
    • CodeRange 96374–96376 → 100%
    • CodeRange 96365–96368 → 100%
    • CodeRange 96409–96409 → 100%
    • CodeRange 96411–96411 → 100%
    • CodeRange 96413–96417 → 100%
    • CodeRange 96360–96361 → 100%
    • CodeRange 90460–90461 → 100%
    • CodeRange 90473–90474 → 100%
    • CodeRange 74184–79999 → 175%
    • CodeRange 72150–72194 → 175%
    • CodeRange 72195–72197 → 205%
    • CodeRange 72198–73220 → 175%
    • CodeRange 73221–73221 → 205%
    • CodeRange 73222–73719 → 175%
    • CodeRange 73720–73721 → 205%
    • CodeRange 73722–74181 → 175%
    • CodeRange 74182–74183 → 205%
    • CodeRange 37227–37227 → 161%
  11. 153% of Medicare RVU (rates as of 2025-01-01)
    • CodeRange 70551–70553 → 205%
    • CodeRange 73221–73221 → 205%
    • CodeRange 70554–72140 → 175%
    • CodeRange 95800–95811 → 155%
    • CodeRange 36470–36471 → 175%
    • CodeRange 36475–36475 → 175%
    • CodeRange 93015–93016 → 175%
    • CodeRange 70010–70550 → 175%
    • CodeRange 37765–37766 → 175%
    • CodeRange 96372–96372 → 100%
    • CodeRange 96374–96376 → 100%
    • CodeRange 96365–96368 → 100%
    • CodeRange 96409–96409 → 100%
    • CodeRange 96411–96411 → 100%
    • CodeRange 96413–96417 → 100%
    • CodeRange 96360–96361 → 100%
    • CodeRange 90460–90461 → 100%
    • CodeRange 90473–90474 → 100%
    • CodeRange 72141–72149 → 205%
    • CodeRange 72150–72194 → 175%
    • CodeRange 72195–72197 → 205%
    • CodeRange 72198–73220 → 175%
    • CodeRange 74184–79999 → 175%
    • CodeRange 73222–73719 → 175%
    • CodeRange 73720–73721 → 205%
    • CodeRange 73722–74181 → 175%
    • CodeRange 74182–74183 → 205%
    • CodeRange 93018–93018 → 175%
  12. 0% of billed charges
Adjustments — all apply, in order
  1. Medicare bilateral-surgery adjustment
  2. Medicare multiple-procedure reduction — base codes 2, 3; pays 100/50/50/50/50/50%
  3. cap the account total at 100% of billed charges
  4. Medicare multiple-procedure reduction — base codes 5; pays 100/0%
  5. modifier CQ present → 85% of the running amount
  6. modifier 52 present → 50% of the running amount
MVP-Medicare-Profee-Clinic4 base · 4 adj
MVP Medicare
Profee · all facilities · 2025-01-01 → 2999-12-31
Base terms — first match wins
  1. 80% of Medicare DME (NY)
  2. 100% of Medicare drug
    • CodeRange 8100–81003 → 80%
    • CodeRange 81025–81025 → 80%
    • CodeRange 82044–82044 → 80%
    • CodeRange 82270–82270 → 80%
    • CodeRange 82465–82465 → 80%
    • CodeRange 82947–82947 → 80%
    • CodeRange 82962–82962 → 80%
    • CodeRange 83036–83036 → 80%
    • CodeRange 83655–83655 → 80%
    • CodeRange 84443–84443 → 80%
    • CodeRange 85013–85018 → 80%
    • CodeRange 85610–85610 → 80%
    • CodeRange 86231–86231 → 80%
    • CodeRange 86308–86308 → 80%
    • CodeRange 86318–86318 → 80%
    • CodeRange 87430–87430 → 80%
    • CodeRange 87804–87804 → 80%
    • CodeRange 87880–87880 → 80%
    • CodeRange G0001–G0001 → 80%
    • CodeRange 36416–36416 → 80%
  3. 80% of Medicare lab (NY)
  4. 115% of Medicare RVU
    • CodeRange 70000–79999 → 100%
Adjustments — all apply, in order
  1. Medicare multiple-procedure reduction — base codes 2
  2. Medicare bilateral-surgery adjustment
  3. mid-level provider reduction (by NUCC taxonomy)
  4. cap the account total at 100% of billed charges
Medicare4 base · 10 adj
Aetna Medicare, Medicare
Profee · all facilities · 2024-01-01 → 2999-12-31
Base terms — first match wins
  1. 100% of Medicare DME (NY)
  2. 100% of Medicare drug
  3. 100% of Medicare lab (NY)
  4. 100% of Medicare RVU
Adjustments — all apply, in order
  1. Medicare multiple-procedure reduction — base codes 2
  2. Medicare bilateral-surgery adjustment
  3. mid-level provider reduction (by NUCC taxonomy)
  4. Medicare multiple-therapy reduction (MPPR) — base codes 5; pays 100/50%
  5. modifier CQ present → 85% of the running amount
  6. modifier 22 present → 135% of the running amount
  7. modifier 62 present → 62.5% of the running amount
  8. modifier 78 present → 70% of the running amount
  9. cap the account total at 100% of billed charges
  10. modifier 80 present → 16% of the running amount
UHC-Allpayer-Profee-Clinic18 base · 8 adj
United Healthcare
Profee · Clinic · 2024-07-15 → 2999-12-31
Base terms — first match wins
  1. flat $0 — when CodeRange in G2211–G2211
  2. 100% of the United Healthcare All Payers-Carveout-Fees fee schedule
  3. 100% of the United Healthcare All Payers-Profee-Midlevel-NonFacility-Fees fee schedule — when ProviderType in Nurse Practitioner, Nurse Practitioner family, Physician Assistant
  4. 100% of the United Healthcare All Payers-Profee-NonFacility-Fees fee schedule
  5. computed expression (operands follow)
  6. 100% of the UHC-Multiplier-Rates fee schedule
  7. Multiply 100% of Medicare drug
  8. computed expression (operands follow)
  9. 100% of the UHC-Multiplier-Rates fee schedule
  10. Multiply 100% of Medicare DME (NY)
  11. computed expression (operands follow)
  12. 100% of the UHC-Multiplier-Rates fee schedule
  13. Multiply 100% of Medicare lab (rates as of 2020-02-01)
  14. computed expression (operands follow)
  15. 100% of the UHC-Multiplier-Rates fee schedule
  16. Multiply 100% of Medicare RVU (rates as of 2020-02-01)
  17. 100% of Medicare drug
  18. 40% of billed charges
Adjustments — all apply, in order
  1. mid-level provider reduction (by NUCC taxonomy)
  2. Medicare multiple-procedure reduction — base codes 5; pays 100/75/75/75/75/75%
  3. Medicare multiple-radiology reduction — base codes 4
  4. Medicare bilateral-surgery adjustment
  5. Medicare multiple-procedure reduction — base codes 2, 3; pays 100/50/50/50/50/50%
  6. modifier 52 present → 50% of the running amount
  7. modifier 53 present → 25% of the running amount
  8. cap each charge and the account total at 100% of billed charges
UHC-Allpayer-Profee-Facility16 base · 8 adj
United Healthcare
Profee · ASC, Hospital, Urgent Care Facility · 2024-07-15 → 2999-12-31
Base terms — first match wins
  1. flat $0 — when CodeRange in G2211–G2211
  2. 100% of the United Healthcare All Payers-Carveout-Fees fee schedule
  3. computed expression (operands follow)
  4. 100% of the UHC-Multiplier-Rates fee schedule
  5. Multiply 100% of Medicare drug
  6. computed expression (operands follow)
  7. 100% of the UHC-Multiplier-Rates fee schedule
  8. Multiply 100% of Medicare DME (NY)
  9. computed expression (operands follow)
  10. 100% of the UHC-Multiplier-Rates fee schedule
  11. Multiply 100% of Medicare lab (rates as of 2020-02-01)
  12. computed expression (operands follow)
  13. 100% of the UHC-Multiplier-Rates fee schedule
  14. Multiply 100% of Medicare RVU (rates as of 2020-02-01)
  15. 100% of Medicare drug
  16. 40% of billed charges
Adjustments — all apply, in order
  1. mid-level provider reduction (by NUCC taxonomy)
  2. Medicare multiple-radiology reduction — base codes 4
  3. Medicare bilateral-surgery adjustment
  4. Medicare multiple-procedure reduction — base codes 2, 3; pays 100/50/50/50/50/50%
  5. modifier CQ present → 85% of the running amount
  6. Medicare multiple-therapy reduction (MPPR) — base codes 5; pays 100/50%
  7. cap each charge and the account total at 100% of billed charges
  8. modifier 52 present → 50% of the running amount
UHC-OxfordLiberty-Allpayer-Profee-Clinic5 base · 5 adj
United Healthcare Oxford Liberty
Profee · all facilities · 2025-07-01 → 2999-12-31
Base terms — first match wins
  1. flat $0 — when CodeRange in G2211–G2211
  2. 100% of the United Healthcare All Payers-Carveout-Fees fee schedule
  3. 100% of the United Healthcare Oxford Liberty All Payers-Profee-Midlevel-NonFacility-Fees fee schedule — when ProviderType in Nurse Practitioner, Nurse Practitioner family, Physician Assistant
  4. 100% of the United Healthcare Oxford Liberty All Payers-Profee-NonFacility-Fees fee schedule
  5. 40% of billed charges
Adjustments — all apply, in order
  1. Medicare multiple-radiology reduction — base codes 4
  2. Medicare bilateral-surgery adjustment
  3. Medicare multiple-procedure reduction — base codes 2, 3; pays 100/50/50/50/50/50%
  4. modifier CQ present → 85% of the running amount
  5. 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.

Anthem-Profee · contract map selects nothing1 base · 18 adj
— no insurance selected —
— no bill type selected — · — nothing selected — · 2026-02-24 → 2999-12-31
Base terms — first match wins
  1. 100% of Medicare RVU (rates as of 2024-01-01)
    • CodeRange 99201–99999 → 132%
    • CodeRange 70000–79999 → 120%
    • CodeRange 30000–39999 → 120%
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
Emblem-Profee · contract map selects nothing2 base · 18 adj
— no insurance selected —
— no bill type selected — · — nothing selected — · 2026-02-24 → 2999-12-31
Base terms — first match wins
  1. 100% of Medicare RVU
    • CodeRange 96360–96549 → 186%
    • CodeRange 80000–89999 → 70%
    • CodeRange 30000–39999 → 120%
  2. 45% 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
Empire-Profee-Clinic · no contract map4 base · 10 adj
no contract map — cannot be resolved
Base terms — first match wins
  1. 85% of the Empire-Profee-Clinic-NonFacilityFees fee schedule — when ProviderType in Nutrition, Podiatry, Pulmonary
  2. 100% of the Empire-Profee-Clinic-Carveout-Fees fee schedule
  3. 100% of the Empire-Profee-Clinic-NonFacilityFees fee schedule
  4. 40% of billed charges
Adjustments — all apply, in order
  1. Medicare multiple-radiology reduction — base codes 4
  2. Medicare bilateral-surgery adjustment
  3. Medicare multiple-procedure reduction — base codes 2, 3; pays 100/50/50/50/50/50%
  4. mid-level provider reduction (by NUCC taxonomy) — when CodeRange in 10021–69990
  5. mid-level provider reduction (by NUCC taxonomy) — when CodeRange in 70010–79999
  6. mid-level provider reduction (by NUCC taxonomy) — when CodeRange in 90281–98999
  7. mid-level provider reduction (by NUCC taxonomy) — when CodeRange in 99091–99499
  8. modifier 53 present → 50% of the running amount
  9. modifier 52 present → 50% of the running amount
  10. cap each charge and the account total at 100% of billed charges
MVP-Medicaid-Profee-Clinic · contract map selects nothing9 base · 4 adj
— no insurance selected —
— no bill type selected — · — nothing selected — · 2026-06-24 → 2999-12-31
Base terms — first match wins
  1. flat $165 — when PlaceOfService 20 is present; CodeRange in S9083–S9083
  2. 115% of Medicare DME (NY) — when ProviderType in Advanced Practice Midwife, Allergy/Immunology, Cardiology, Cardiology Interventionalist +24
  3. 100% of Medicare DME (NY)
  4. 115% of Medicare drug — when ProviderType in Advanced Practice Midwife, Allergy/Immunology, Cardiology, Cardiology Interventionalist +24
  5. 100% of Medicare drug
  6. 115% of Medicare lab (NY) — when ProviderType in Advanced Practice Midwife, Allergy/Immunology, Cardiology, Cardiology Interventionalist +24
  7. 100% of Medicare lab (NY)
  8. 115% of Medicare RVU — when ProviderType in Advanced Practice Midwife, Allergy/Immunology, Cardiology, Cardiology Interventionalist +24
    • CodeRange 70000–79999 → 100%
  9. 100% of Medicare RVU
    • CodeRange 70000–79999 → 100%
Adjustments — all apply, in order
  1. Medicare multiple-procedure reduction — base codes 2
  2. Medicare bilateral-surgery adjustment
  3. mid-level provider reduction (by NUCC taxonomy)
  4. cap the account total at 100% of billed charges
Medicare · no contract map4 base · 4 adj
no contract map — cannot be resolved
Base terms — first match wins
  1. 100% of Medicare DME (NY)
  2. 100% of Medicare drug
  3. 100% of Medicare lab (NY)
  4. 100% of Medicare RVU
Adjustments — all apply, in order
  1. Medicare multiple-procedure reduction — base codes 2
  2. Medicare bilateral-surgery adjustment
  3. mid-level provider reduction (by NUCC taxonomy)
  4. cap the account total at 100% of billed charges
UHC-Allpayer-Profee-Clinic-Profee (Replaced by UHC Multiplier Logic) · no contract map4 base · 9 adj
no contract map — cannot be resolved
Base terms — first match wins
  1. 100% of the United Healthcare All Payers-Carveout-Fees fee schedule
  2. 100% of the United Healthcare All Payers-Profee-Midlevel-NonFacility-Fees fee schedule — when ProviderType in Nurse Practitioner, Nurse Practitioner family, Physician Assistant
  3. 100% of the United Healthcare All Payers-Profee-NonFacility-Fees fee schedule
  4. 40% of billed charges
Adjustments — all apply, in order
  1. Medicare multiple-radiology reduction — base codes 4
  2. Medicare bilateral-surgery adjustment
  3. Medicare multiple-procedure reduction — base codes 2, 3; pays 100/50/50/50/50/50%
  4. mid-level provider reduction (by NUCC taxonomy) — when CodeRange in 10021–69990
  5. mid-level provider reduction (by NUCC taxonomy) — when CodeRange in 70010–79999
  6. mid-level provider reduction (by NUCC taxonomy) — when CodeRange in 90281–98999
  7. mid-level provider reduction (by NUCC taxonomy) — when CodeRange in 99091–99499
  8. modifier CQ present → 85% of the running amount
  9. cap each charge and the account total at 100% of billed charges