Customer detail

MNEye

123
live contracts
17
cannot fire
21
calc types
58
SQL bodies
0
of those blocked
5
map conflicts

Methodology mix

ModifierAdjustment803
PercentOfFees233
SqlExpression199
LesserOfAdjustment127
ChargeLevelSqlAdjustment67
FlatPercentOfCharges59
MedicareMultipleSurgeryAdjustment44
MedicareMultipleProcedureAdjustment41
MultipleSurgeryAdjustment37
PercentageAdjustment35
FlatFee29
MultipleProcedureAdjustment27
ExcludedChargeAdjustment26
MidLevelProviderAdjustment19
MedicareASC18
MultipleEndoscopyAdjustment18
MedicareRVU16
MedicareDrug15
MedicareLab14
MedicareDME14
MedicareMultipleEndoscopyAdjustment14

Contracts

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

Aetna Allina Health Commercial4 base · 16 adj
Aetna Allina Health Commercial
Profee · Minnesota Eye Consultants, Minnesota Eye Laser And Surgery Centers, Minnesota Retina Associates, Northwest Eye Clinic, Southwest Eye Care · 2024-08-01 → 2099-12-31
Base terms — first match wins
  1. 0% of the Non-Covered-Services fee schedule
  2. custom SQL — A cosmetic/no-charge carve-out override: for charges whose extracted code fields flag them as 'no charge' (CS='NC'), cosmetic (CT like COS/S9999MN), or specific vision codes (V2786F/V2787F/V27878F), it returns the billed charge as-is (or zero when the billed charge is itself zero) instead of running normal fee-schedule pricing.
  3. 100% of the Aetna-Market-Fee-Schedule fee schedule
  4. flat $0
Adjustments — all apply, in order
  1. modifier 1 present → 0% of the running amount
  2. modifier Y present → 0% of the running amount
  3. Medicare multiple-endoscopy reduction
  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 50 present → 150% of the running amount
  8. modifier 52 present → 50% of the running amount
  9. modifier 54 present → 80% of the running amount
  10. modifier 62 present → 62.5% of the running amount
  11. modifier 78 present → 70% of the running amount
  12. modifier 80 present → 16% of the running amount
  13. modifier 81 present → 16% of the running amount
  14. modifier 82 present → 16% of the running amount
  15. modifier AS present → 13.6% of the running amount
  16. cap each charge and the account total at 100% of billed charges
Aetna Allina Health Commercial - ASC5 base · 7 adj
Aetna Allina Health Commercial
Facility · all facilities · 2025-01-01 → 2999-12-31
Base terms — first match wins
  1. 0% of the Non-Covered-Services fee schedule
  2. custom SQL — A cosmetic/no-charge carve-out override: for charges whose extracted code fields flag them as 'no charge' (CS='NC'), cosmetic (CT like COS/S9999MN), or specific vision codes (V2786F/V2787F/V27878F), it returns the billed charge as-is (or zero when the billed charge is itself zero) instead of running normal fee-schedule pricing.
  3. flat $4300 — when ProcCodeFilter V2785 is present
  4. 190% of Medicare ASC
  5. 30% of billed charges
Adjustments — all apply, in order
  1. modifier 1 present → 0% of the running amount
  2. modifier Y present → 0% of the running amount
  3. Medicare multiple-endoscopy reduction
  4. modifier 50 present → 150% of the running amount
  5. modifier 52 present → 50% of the running amount
  6. Medicare multiple-surgery reduction — pays 100/50%
  7. cap each charge and the account total at 100% of billed charges
Aetna Allina Health Senior Plan10 base · 17 adj
Aetna Allina Health Senior Plan
Profee · Minnesota Eye Consultants, Minnesota Eye Laser And Surgery Centers, Minnesota Retina Associates, Northwest Eye Clinic, Southwest Eye Care · 2016-01-01 → 2099-12-31
Base terms — first match wins
  1. 0% of the Non-Covered-Services fee schedule
  2. custom SQL — A cosmetic/no-charge carve-out override: for charges whose extracted code fields flag them as 'no charge' (CS='NC'), cosmetic (CT like COS/S9999MN), or specific vision codes (V2786F/V2787F/V27878F), it returns the billed charge as-is (or zero when the billed charge is itself zero) instead of running normal fee-schedule pricing.
  3. 100% of the Medicare-Contractor-Codes fee schedule
  4. 100% of the Medicare-Exceptions fee schedule
  5. 100% of Medicare drug
  6. 100% of Medicare lab
  7. 100% of Medicare DME
  8. 100% of Medicare RVU
  9. 100% of Medicare ASC
  10. flat $0
Adjustments — all apply, in order
  1. custom SQL — Hardcoded flat fees for CPT 92015 (refraction) that vary by calendar year: $19.40 for 2019, $19.94 for 2020, $19.41 for 2021.
  2. modifier 1 present → 0% of the running amount
  3. modifier Y present → 0% of the running amount
  4. Medicare multiple-endoscopy reduction
  5. Medicare multiple-procedure reduction — base codes 2, 3; pays 100/50%
  6. mid-level provider reduction (by NUCC taxonomy)
  7. modifier 22 present → 135% of the running amount
  8. modifier 50 present → 150% of the running amount
  9. modifier 52 present → 50% of the running amount
  10. modifier 54 present → 80% of the running amount
  11. modifier 62 present → 62.5% of the running amount
  12. modifier 78 present → 70% of the running amount
  13. modifier 80 present → 16% of the running amount
  14. modifier 81 present → 16% of the running amount
  15. modifier 82 present → 16% of the running amount
  16. modifier AS present → 13.6% of the running amount
  17. cap each charge and the account total at 100% of billed charges
Aetna Allina Health Senior Plan-ASC6 base · 7 adj
Aetna Allina Health Senior Plan
Facility · Hospital/ASC · 2016-01-01 → 2099-12-31
Base terms — first match wins
  1. 0% of the Non-Covered-Services fee schedule
  2. custom SQL — A cosmetic/no-charge carve-out override: for charges whose extracted code fields flag them as 'no charge' (CS='NC'), cosmetic (CT like COS/S9999MN), or specific vision codes (V2786F/V2787F/V27878F), it returns the billed charge as-is (or zero when the billed charge is itself zero) instead of running normal fee-schedule pricing.
  3. 100% of billed charges — when ProcCodeFilter V2785 is present
  4. 100% of billed charges — when ProcCodeFilter J1097 is present
  5. 100% of Medicare ASC
  6. flat $0
Adjustments — all apply, in order
  1. modifier 1 present → 0% of the running amount
  2. modifier Y present → 0% of the running amount
  3. Medicare multiple-endoscopy reduction
  4. Medicare multiple-surgery reduction — pays 100/50%
  5. modifier 50 present → 150% of the running amount
  6. modifier 52 present → 50% of the running amount
  7. cap each charge and the account total at 100% of billed charges
Aetna Medicare10 base · 17 adj
Aetna Medicare
Profee · all facilities · 2016-01-01 → 2099-12-31
Base terms — first match wins
  1. 0% of the Non-Covered-Services fee schedule
  2. custom SQL — A cosmetic/no-charge carve-out override: for charges whose extracted code fields flag them as 'no charge' (CS='NC'), cosmetic (CT like COS/S9999MN), or specific vision codes (V2786F/V2787F/V27878F), it returns the billed charge as-is (or zero when the billed charge is itself zero) instead of running normal fee-schedule pricing.
  3. 100% of the Medicare-Contractor-Codes fee schedule
  4. 100% of the Medicare-Exceptions fee schedule
  5. 100% of the Medicare-Drug fee schedule
  6. 100% of the Medicare-Lab fee schedule
  7. 100% of the Medicare-DME fee schedule
  8. custom SQL — A flat fee-schedule lookup labeled 'Medicare-RVU-Hospital'/'Medicare-RVU-Clinic' that selects a schedule row by facility type, returning fee * Units — despite the name, this does not compute an actual Medicare RVU price, it's a plain customer-maintained fee schedule.
  9. 100% of the Medicare-ASC fee schedule
  10. flat $0
Adjustments — all apply, in order
  1. custom SQL — Flat per-unit price for CPT 92015 (refraction), $19.33 for dates in 2018-2019 and $19.72 for dates in 2020-2021.
  2. modifier 1 present → 0% of the running amount
  3. modifier Y present → 0% of the running amount
  4. multiple-endoscopy reduction (contract rules)
  5. multiple-procedure reduction (contract rules) — base codes 2, 3; pays 100/50%
  6. rescale by a percentage read from the Mid-Level-Charges schedule — when MidLevelProviders Mid-Level is present
  7. modifier 22 present → 135% of the running amount
  8. modifier 50 present → 150% of the running amount
  9. modifier 52 present → 50% of the running amount
  10. modifier 54 present → 80% of the running amount
  11. modifier 62 present → 62.5% of the running amount
  12. modifier 78 present → 70% of the running amount
  13. modifier 80 present → 16% of the running amount
  14. modifier 81 present → 16% of the running amount
  15. modifier 82 present → 16% of the running amount
  16. modifier AS present → 13.6% of the running amount
  17. cap each charge and the account total at 100% of billed charges
Aetna Medicare-ASC5 base · 8 adj
Aetna Medicare
Facility · Hospital/ASC · 2016-01-01 → 2099-12-31
Base terms — first match wins
  1. 0% of the Non-Covered-Services fee schedule
  2. custom SQL — A cosmetic/no-charge carve-out override: for charges whose extracted code fields flag them as 'no charge' (CS='NC'), cosmetic (CT like COS/S9999MN), or specific vision codes (V2786F/V2787F/V27878F), it returns the billed charge as-is (or zero when the billed charge is itself zero) instead of running normal fee-schedule pricing.
  3. custom SQL — Single-code override, functionally identical to hash 8f8e9be6eea48e6c: for CPT V2785, pay the billed charge in full instead of running normal pricing (with an explicit decimal cast).
  4. 100% of the Medicare-ASC fee schedule
  5. flat $0
Adjustments — all apply, in order
  1. custom SQL — Duplicate of idx31/idx47: pays compounded ophthalmic drug J1097 at full billed charges for dates of service on/after 1/1/2019, for a different customer or FeeLogic.
  2. modifier 1 present → 0% of the running amount
  3. modifier Y present → 0% of the running amount
  4. multiple-endoscopy reduction (contract rules)
  5. modifier 50 present → 150% of the running amount
  6. modifier 52 present → 50% of the running amount
  7. cap each charge and the account total at 100% of billed charges
  8. multiple-surgery reduction (contract rules) — pays 100/50%
Blue-Cross3 base · 9 adj
Blue Cross
Profee · all facilities · 2015-07-01 → 2019-12-31
Base terms — first match wins
  1. custom SQL — A cosmetic/no-charge carve-out override: for charges whose extracted code fields flag them as 'no charge' (CS='NC'), cosmetic (CT like COS/S9999MN), or specific vision codes (V2786F/V2787F/V27878F), it returns the billed charge as-is (or zero when the billed charge is itself zero) instead of running normal fee-schedule pricing.
  2. 102% of the Fixed-Fees fee schedule ⚠︎ named “100% of Non-RVU Rates + 2% MN Care Tax” but configured at 102%
  3. custom SQL — Same Profee Hospital/Clinic fee lookup as sql_hash 4f7320fe47f9e781, with a flat 1.02 uplift on top.
Adjustments — all apply, in order
  1. modifier 1 present → 0% of the running amount
  2. modifier Y present → 0% of the running amount
  3. rescale by a percentage read from the Mid-Level-Charges schedule — when MidLevelProviders Mid-Level is present
  4. modifier 50 present → 150% of the running amount
  5. modifier 52 present → 90% of the running amount
  6. modifier 54 present → 80% of the running amount
  7. modifier 78 present → 90% of the running amount
  8. Medicare multiple-procedure reduction — base codes 2, 3; pays 100/50%
  9. cap each charge and the account total at 100% of billed charges
Blue-Cross-20203 base · 9 adj
Blue Cross
Profee · all facilities · 2020-01-01 → 2022-12-31
Base terms — first match wins
  1. custom SQL — A cosmetic/no-charge carve-out override: for charges whose extracted code fields flag them as 'no charge' (CS='NC'), cosmetic (CT like COS/S9999MN), or specific vision codes (V2786F/V2787F/V27878F), it returns the billed charge as-is (or zero when the billed charge is itself zero) instead of running normal fee-schedule pricing.
  2. 101.8% of the Fixed-Fees fee schedule ⚠︎ named “100% of Non-RVU Rates + 1.8% MN Care Tax” but configured at 101.8%
  3. custom SQL — Same Profee-Hospital/Profee-Clinic fee-schedule lookup as 171 (highest-priority row via POS-code-indicator crosswalk), but with a 1.018 inflation factor instead of 1.016.
Adjustments — all apply, in order
  1. modifier 1 present → 0% of the running amount
  2. modifier Y present → 0% of the running amount
  3. rescale by a percentage read from the Mid-Level-Charges schedule — when MidLevelProviders Mid-Level is present
  4. modifier 50 present → 150% of the running amount
  5. modifier 52 present → 90% of the running amount
  6. modifier 54 present → 80% of the running amount
  7. modifier 78 present → 90% of the running amount
  8. Medicare multiple-procedure reduction — base codes 2, 3; pays 100/50%
  9. cap each charge and the account total at 100% of billed charges
Blue-Cross-20233 base · 9 adj
Blue Cross
Profee · Minnesota Eye Consultants, Minnesota Eye Laser And Surgery Centers, Minnesota Retina Associates, Northwest Eye Clinic, Southwest Eye Care · 2023-01-01 → 2023-12-31
Base terms — first match wins
  1. custom SQL — A cosmetic/no-charge carve-out override: for charges whose extracted code fields flag them as 'no charge' (CS='NC'), cosmetic (CT like COS/S9999MN), or specific vision codes (V2786F/V2787F/V27878F), it returns the billed charge as-is (or zero when the billed charge is itself zero) instead of running normal fee-schedule pricing.
  2. 101.6% of the Fixed-Fees fee schedule ⚠︎ named “100% of Non-RVU Rates + 1.6% MN Care Tax” but configured at 101.6%
  3. custom SQL — Profee fee-schedule lookup: selects the highest-priority Profee-Hospital or Profee-Clinic fee row for the charge's code+modifier at this facility/insurance, picks Facility vs Non-Facility rate based on a POS-code-indicator crosswalk, and returns Amount x 1.016 (annual inflation factor) x Units.
Adjustments — all apply, in order
  1. modifier 1 present → 0% of the running amount
  2. modifier Y present → 0% of the running amount
  3. rescale by a percentage read from the Mid-Level-Charges schedule — when MidLevelProviders Mid-Level is present
  4. modifier 50 present → 150% of the running amount
  5. modifier 52 present → 90% of the running amount
  6. modifier 54 present → 80% of the running amount
  7. modifier 78 present → 90% of the running amount
  8. Medicare multiple-procedure reduction — base codes 2, 3; pays 100/50%
  9. cap each charge and the account total at 100% of billed charges
Blue-Cross-20243 base · 10 adj
Blue Cross
Profee · Minnesota Eye Consultants, Minnesota Eye Laser And Surgery Centers, Minnesota Retina Associates, Northwest Eye Clinic, Southwest Eye Care · 2024-01-01 → 2099-12-31
Base terms — first match wins
  1. custom SQL — A cosmetic/no-charge carve-out override: for charges whose extracted code fields flag them as 'no charge' (CS='NC'), cosmetic (CT like COS/S9999MN), or specific vision codes (V2786F/V2787F/V27878F), it returns the billed charge as-is (or zero when the billed charge is itself zero) instead of running normal fee-schedule pricing.
  2. 101.8% of the Fixed-Fees fee schedule ⚠︎ named “100% of Non-RVU Rates + 1.8% MN Care Tax” but configured at 101.8%
  3. custom SQL — Same Profee fee-schedule lookup as idx32/37/44 (facility/insurance/date-scoped fee by CT code and modifier, POS-adjusted), with an extra flat 1.8% markup baked directly into the query (*1.018).
Adjustments — all apply, in order
  1. modifier 1 present → 0% of the running amount
  2. modifier Y present → 0% of the running amount
  3. rescale by a percentage read from the Mid-Level-Charges schedule — when MidLevelProviders Mid-Level is present
  4. modifier 50 present → 150% of the running amount
  5. modifier 25 present → 80% of the running amount
  6. modifier 52 present → 90% of the running amount
  7. modifier 54 present → 80% of the running amount
  8. modifier 78 present → 90% of the running amount
  9. Medicare multiple-procedure reduction — base codes 2, 3; pays 100/50%
  10. cap each charge and the account total at 100% of billed charges
Blue-Cross-ASC2 base · 8 adj
Blue Cross
Facility · Hospital/ASC · 2015-07-01 → 2019-12-31
Base terms — first match wins
  1. custom SQL — A cosmetic/no-charge carve-out override: for charges whose extracted code fields flag them as 'no charge' (CS='NC'), cosmetic (CT like COS/S9999MN), or specific vision codes (V2786F/V2787F/V27878F), it returns the billed charge as-is (or zero when the billed charge is itself zero) instead of running normal fee-schedule pricing.
  2. 102% of the EAPG-Rates fee schedule ⚠︎ named “100% of EAPG Rates + 2% MN Care Tax” but configured at 102%
Adjustments — all apply, in order
  1. modifier 1 present → 0% of the running amount
  2. modifier Y present → 0% of the running amount
  3. modifier 50 present → 150% of the running amount
  4. modifier 52 present → 90% of the running amount
  5. modifier 78 present → 90% of the running amount
  6. Medicare multiple-surgery reduction — pays 100/50%
  7. cap each charge and the account total at 100% of billed charges
  8. custom SQL — Single-code override: for CPT V2785 (corneal tissue processing), pay the billed charge in full instead of running normal pricing.
Blue-Cross-ASC-20202 base · 8 adj
Blue Cross
Facility · Hospital/ASC · 2020-01-01 → 2020-12-31
Base terms — first match wins
  1. custom SQL — A cosmetic/no-charge carve-out override: for charges whose extracted code fields flag them as 'no charge' (CS='NC'), cosmetic (CT like COS/S9999MN), or specific vision codes (V2786F/V2787F/V27878F), it returns the billed charge as-is (or zero when the billed charge is itself zero) instead of running normal fee-schedule pricing.
  2. 101.8% of the EAPG-Rates fee schedule ⚠︎ named “100% of EAPG Rates + 1.8% MN Care Tax” but configured at 101.8%
Adjustments — all apply, in order
  1. modifier 1 present → 0% of the running amount
  2. modifier Y present → 0% of the running amount
  3. modifier 50 present → 150% of the running amount
  4. modifier 52 present → 90% of the running amount
  5. modifier 78 present → 90% of the running amount
  6. Medicare multiple-surgery reduction — pays 100/50%
  7. cap each charge and the account total at 100% of billed charges
  8. custom SQL — Single-code override: for CPT V2785 (corneal tissue processing), pay the billed charge in full instead of running normal pricing.
Blue-Cross-ASC-20213 base · 8 adj
Blue Cross
Facility · Hospital/ASC · 2021-01-01 → 2022-12-31
Base terms — first match wins
  1. custom SQL — A cosmetic/no-charge carve-out override: for charges whose extracted code fields flag them as 'no charge' (CS='NC'), cosmetic (CT like COS/S9999MN), or specific vision codes (V2786F/V2787F/V27878F), it returns the billed charge as-is (or zero when the billed charge is itself zero) instead of running normal fee-schedule pricing.
  2. 101.8% of the EAPG-CarveOut fee schedule ⚠︎ named “100% of EAPG CarveOut + 1.8% MN Care Tax” but configured at 101.8%
  3. 101.8% of the EAPG-Rates fee schedule ⚠︎ named “100% of EAPG Rates + 1.8% MN Care Tax” but configured at 101.8%
Adjustments — all apply, in order
  1. modifier 1 present → 0% of the running amount
  2. modifier Y present → 0% of the running amount
  3. modifier 50 present → 150% of the running amount
  4. modifier 52 present → 90% of the running amount
  5. modifier 78 present → 90% of the running amount
  6. Medicare multiple-surgery reduction — pays 100/50%
  7. custom SQL — Pays a fixed flat dollar amount ($482.86) for compounded ophthalmic drug J1097, unconditionally (no date restriction).
  8. cap each charge and the account total at 100% of billed charges
Blue-Cross-ASC-20233 base · 8 adj
Blue Cross
Facility · Minnesota Eye Consultants, Minnesota Eye Laser And Surgery Centers, Minnesota Retina Associates, Northwest Eye Clinic, Southwest Eye Care, Hospital/ASC · 2023-01-01 → 2023-12-31
Base terms — first match wins
  1. custom SQL — A cosmetic/no-charge carve-out override: for charges whose extracted code fields flag them as 'no charge' (CS='NC'), cosmetic (CT like COS/S9999MN), or specific vision codes (V2786F/V2787F/V27878F), it returns the billed charge as-is (or zero when the billed charge is itself zero) instead of running normal fee-schedule pricing.
  2. 101.6% of the EAPG-CarveOut fee schedule ⚠︎ named “100% of EAPG CarveOut + 1.6% MN Care Tax” but configured at 101.6%
  3. 101.6% of the EAPG-Rates fee schedule ⚠︎ named “100% of EAPG Rates + 1.6% MN Care Tax” but configured at 101.6%
Adjustments — all apply, in order
  1. modifier 1 present → 0% of the running amount
  2. modifier Y present → 0% of the running amount
  3. modifier 50 present → 150% of the running amount
  4. modifier 52 present → 90% of the running amount
  5. modifier 78 present → 90% of the running amount
  6. Medicare multiple-surgery reduction — pays 100/50%
  7. custom SQL — Pays a fixed flat dollar amount ($482.86) for compounded ophthalmic drug J1097, unconditionally (no date restriction).
  8. cap each charge and the account total at 100% of billed charges
Blue-Cross-ASC-20244 base · 9 adj
Blue Cross
Facility · Minnesota Eye Consultants, Minnesota Eye Laser And Surgery Centers, Minnesota Retina Associates, Northwest Eye Clinic, Southwest Eye Care, Hospital/ASC · 2024-01-01 → 2099-12-31
Base terms — first match wins
  1. custom SQL — A small set of full-charge-or-zero carve-out rules: no-charge/'NC' claim status pays full billed charge; cash-pay charge types (COS/S9999MN) pay full charge unless $0 billed (then $0); any other $0-billed line pays $0; and three specific vision-refraction codes (V2786F/V2787F/V27878F) always pay full charge.
  2. 101.8% of the BC-Carve-Outs fee schedule ⚠︎ named “100% of BC Commercial Fees + 1.8% MN Care Tax” but configured at 101.8%
  3. 100% of billed charges — when ProcCodeFilter V2785 is present
  4. 25% of billed charges
Adjustments — all apply, in order
  1. modifier 1 present → 0% of the running amount
  2. modifier Y present → 0% of the running amount
  3. modifier 50 present → 150% of the running amount
  4. modifier 25 present → 80% of the running amount
  5. modifier 52 present → 90% of the running amount
  6. modifier 78 present → 90% of the running amount
  7. Medicare multiple-surgery reduction — pays 100/50%
  8. custom SQL — Pays a fixed flat dollar amount ($482.86) for compounded ophthalmic drug J1097, unconditionally (no date restriction).
  9. cap each charge and the account total at 100% of billed charges
Blue-Cross-BackUp3 base · 9 adj
Blue Cross
Profee · all facilities · 2015-07-01 → 2019-12-31
Base terms — first match wins
  1. custom SQL — Cosmetic/no-charge carve-out override, same family as hash ca6756740e819542 (index 2) but missing that snippet's fourth block for the specific V27xx vision codes: pays full billed charge for 'NC' or cosmetic (COS/S9999MN) coded lines, zeroing cosmetic lines with $0 charge.
  2. 102% of the Fixed-Fees fee schedule ⚠︎ named “100% of Non-RVU Rates + 2% MN Care Tax” but configured at 102%
  3. custom SQL — Same Profee fee-schedule lookup as idx32/36/37, with an extra flat 2% markup baked directly into the query (*1.02).
Adjustments — all apply, in order
  1. modifier 1 present → 0% of the running amount
  2. modifier Y present → 0% of the running amount
  3. rescale by a percentage read from the Mid-Level-Charges schedule — when MidLevelProviders Mid-Level is present
  4. modifier 50 present → 150% of the running amount
  5. modifier 52 present → 90% of the running amount
  6. modifier 54 present → 80% of the running amount
  7. modifier 78 present → 90% of the running amount
  8. Medicare multiple-procedure reduction — base codes 2; pays 100/50%
  9. cap each charge and the account total at 100% of billed charges
Blue-Cross-FEP3 base · 10 adj
Blue Cross FEP
Profee · Minnesota Eye Consultants, Minnesota Eye Laser And Surgery Centers, Minnesota Retina Associates, Northwest Eye Clinic, Southwest Eye Care · 2015-07-01 → 2099-06-30
Base terms — first match wins
  1. custom SQL — A cosmetic/no-charge carve-out override: for charges whose extracted code fields flag them as 'no charge' (CS='NC'), cosmetic (CT like COS/S9999MN), or specific vision codes (V2786F/V2787F/V27878F), it returns the billed charge as-is (or zero when the billed charge is itself zero) instead of running normal fee-schedule pricing.
  2. 100% of the Fixed-Fees fee schedule
  3. custom SQL — Looks up a Profee fee (Hospital vs Clinic schedule chosen via POS-code-indicator lookup by facility type, highest-priority matching modifier filter wins) for the charge's code, multiplied by units.
Adjustments — all apply, in order
  1. modifier 1 present → 0% of the running amount
  2. modifier Y present → 0% of the running amount
  3. rescale by a percentage read from the Mid-Level-Charges schedule — when MidLevelProviders Mid-Level is present
  4. modifier 50 present → 150% of the running amount
  5. modifier 25 present → 80% of the running amount
  6. modifier 52 present → 90% of the running amount
  7. modifier 54 present → 80% of the running amount
  8. modifier 78 present → 90% of the running amount
  9. Medicare multiple-procedure reduction — base codes 2, 3; pays 100/50%
  10. cap each charge and the account total at 100% of billed charges
Blue-Cross-FEP-ASC2 base · 8 adj
Blue Cross FEP
Facility · Hospital/ASC · 2015-07-01 → 2020-12-31
Base terms — first match wins
  1. custom SQL — A cosmetic/no-charge carve-out override: for charges whose extracted code fields flag them as 'no charge' (CS='NC'), cosmetic (CT like COS/S9999MN), or specific vision codes (V2786F/V2787F/V27878F), it returns the billed charge as-is (or zero when the billed charge is itself zero) instead of running normal fee-schedule pricing.
  2. 100% of the EAPG-Rates fee schedule
Adjustments — all apply, in order
  1. modifier 1 present → 0% of the running amount
  2. modifier Y present → 0% of the running amount
  3. modifier 50 present → 150% of the running amount
  4. modifier 52 present → 90% of the running amount
  5. modifier 78 present → 90% of the running amount
  6. Medicare multiple-surgery reduction — pays 100/50%
  7. cap each charge and the account total at 100% of billed charges
  8. custom SQL — Single-code override: for CPT V2785 (corneal tissue processing), pay the billed charge in full instead of running normal pricing.
Blue-Cross-FEP-ASC-20213 base · 8 adj
Blue Cross FEP
Facility · Hospital/ASC · 2021-01-01 → 2023-12-31
Base terms — first match wins
  1. custom SQL — A cosmetic/no-charge carve-out override: for charges whose extracted code fields flag them as 'no charge' (CS='NC'), cosmetic (CT like COS/S9999MN), or specific vision codes (V2786F/V2787F/V27878F), it returns the billed charge as-is (or zero when the billed charge is itself zero) instead of running normal fee-schedule pricing.
  2. 100% of the EAPG-CarveOut fee schedule
  3. 100% of the EAPG-Rates fee schedule
Adjustments — all apply, in order
  1. modifier 1 present → 0% of the running amount
  2. modifier Y present → 0% of the running amount
  3. modifier 50 present → 150% of the running amount
  4. modifier 52 present → 90% of the running amount
  5. modifier 78 present → 90% of the running amount
  6. Medicare multiple-surgery reduction — pays 100/50%
  7. cap each charge and the account total at 100% of billed charges
  8. custom SQL — Single-code override: for CPT V2785 (corneal tissue processing), pay the billed charge in full instead of running normal pricing.
Blue-Cross-FEP-ASC-20244 base · 9 adj
Blue Cross FEP
Facility · Minnesota Eye Consultants, Minnesota Eye Laser And Surgery Centers, Minnesota Retina Associates, Northwest Eye Clinic, Southwest Eye Care, Hospital/ASC · 2024-01-01 → 2999-12-31
Base terms — first match wins
  1. custom SQL — A cosmetic/no-charge carve-out override: for charges whose extracted code fields flag them as 'no charge' (CS='NC'), cosmetic (CT like COS/S9999MN), or specific vision codes (V2786F/V2787F/V27878F), it returns the billed charge as-is (or zero when the billed charge is itself zero) instead of running normal fee-schedule pricing.
  2. 100% of the BC-Carve-Outs fee schedule
  3. 100% of billed charges — when ProcCodeFilter V2785 is present
  4. 25% of billed charges
Adjustments — all apply, in order
  1. modifier 1 present → 0% of the running amount
  2. modifier Y present → 0% of the running amount
  3. modifier 50 present → 150% of the running amount
  4. modifier 25 present → 80% of the running amount
  5. modifier 52 present → 90% of the running amount
  6. modifier 78 present → 90% of the running amount
  7. Medicare multiple-surgery reduction — pays 100/50%
  8. cap each charge and the account total at 100% of billed charges
  9. custom SQL — Single-code override: for CPT V2785 (corneal tissue processing), pay the billed charge in full instead of running normal pricing.
Blue-Cross-MA2 base · 8 adj
Blue Cross MA
Profee · all facilities · 2015-07-01 → 2019-12-31
Base terms — first match wins
  1. custom SQL — A cosmetic/no-charge carve-out override: for charges whose extracted code fields flag them as 'no charge' (CS='NC'), cosmetic (CT like COS/S9999MN), or specific vision codes (V2786F/V2787F/V27878F), it returns the billed charge as-is (or zero when the billed charge is itself zero) instead of running normal fee-schedule pricing.
  2. custom SQL — Profee schedule lookup with site-of-service-aware Facility-vs-Non-Facility schedule selection (via a POS-indicator crosswalk), priced per unit and marked up 3%.
Adjustments — all apply, in order
  1. modifier 1 present → 0% of the running amount
  2. modifier Y present → 0% of the running amount
  3. modifier 50 present → 150% of the running amount
  4. modifier 52 present → 90% of the running amount
  5. modifier 54 present → 80% of the running amount
  6. modifier 78 present → 90% of the running amount
  7. cap each charge and the account total at 100% of billed charges
  8. multiple-procedure reduction (contract rules) — base codes 2, 3; pays 100/50%
Blue-Cross-MA-20202 base · 8 adj
Blue Cross MA
Profee · Minnesota Eye Consultants, Minnesota Eye Laser And Surgery Centers, Minnesota Retina Associates, Northwest Eye Clinic, Southwest Eye Care · 2020-01-01 → 2024-12-31
Base terms — first match wins
  1. custom SQL — A cosmetic/no-charge carve-out override: for charges whose extracted code fields flag them as 'no charge' (CS='NC'), cosmetic (CT like COS/S9999MN), or specific vision codes (V2786F/V2787F/V27878F), it returns the billed charge as-is (or zero when the billed charge is itself zero) instead of running normal fee-schedule pricing.
  2. custom SQL — Same Profee fee-schedule lookup as idx32/37/44 (facility/insurance/date-scoped fee by CT code and modifier, POS-adjusted), with an extra flat 1.8% markup baked directly into the query (*1.018).
Adjustments — all apply, in order
  1. modifier 1 present → 0% of the running amount
  2. modifier Y present → 0% of the running amount
  3. modifier 50 present → 150% of the running amount
  4. modifier 52 present → 90% of the running amount
  5. modifier 54 present → 80% of the running amount
  6. modifier 78 present → 90% of the running amount
  7. cap each charge and the account total at 100% of billed charges
  8. multiple-procedure reduction (contract rules) — base codes 2, 3; pays 100/50%
Blue-Cross-MA-20254 base · 8 adj
Blue Cross MA
Profee · Minnesota Eye Consultants, Minnesota Eye Laser And Surgery Centers, Minnesota Retina Associates, Northwest Eye Clinic, Southwest Eye Care · 2025-01-01 → 2099-12-31
Base terms — first match wins
  1. custom SQL — A cosmetic/no-charge carve-out override: for charges whose extracted code fields flag them as 'no charge' (CS='NC'), cosmetic (CT like COS/S9999MN), or specific vision codes (V2786F/V2787F/V27878F), it returns the billed charge as-is (or zero when the billed charge is itself zero) instead of running normal fee-schedule pricing.
  2. 101.8% of the Profee-Clinic-ProcCode fee schedule — when PlaceOfService 11 is present ⚠︎ named “100% of Blue Cross MA Clinic Fees + 1.8% MN Care Tax” but configured at 101.8%
  3. 101.8% of the Profee-Hospital-ProcCode fee schedule ⚠︎ named “100% of Blue Cross MA Hospital Fees + 1.8% MN Care Tax” but configured at 101.8%
  4. custom SQL — Same Profee fee-schedule lookup as idx32/37/44 (facility/insurance/date-scoped fee by CT code and modifier, POS-adjusted), with an extra flat 1.8% markup baked directly into the query (*1.018).
Adjustments — all apply, in order
  1. modifier 1 present → 0% of the running amount
  2. modifier Y present → 0% of the running amount
  3. modifier 50 present → 150% of the running amount
  4. modifier 52 present → 90% of the running amount
  5. modifier 54 present → 80% of the running amount
  6. modifier 78 present → 90% of the running amount
  7. cap each charge and the account total at 100% of billed charges
  8. multiple-procedure reduction (contract rules) — base codes 2, 3; pays 100/50%
Blue-Cross-MA-ASC2 base · 8 adj
Blue Cross MA
Facility · Hospital/ASC · 2015-07-01 → 2019-12-31
Base terms — first match wins
  1. custom SQL — A cosmetic/no-charge carve-out override: for charges whose extracted code fields flag them as 'no charge' (CS='NC'), cosmetic (CT like COS/S9999MN), or specific vision codes (V2786F/V2787F/V27878F), it returns the billed charge as-is (or zero when the billed charge is itself zero) instead of running normal fee-schedule pricing.
  2. 102% of the EAPG-Rates fee schedule ⚠︎ named “100% of Blue Cross MA EAPG Rates + 2% MN Care Tax” but configured at 102%
Adjustments — all apply, in order
  1. modifier 1 present → 0% of the running amount
  2. modifier Y present → 0% of the running amount
  3. modifier 50 present → 150% of the running amount
  4. modifier 52 present → 90% of the running amount
  5. modifier 78 present → 90% of the running amount
  6. cap each charge and the account total at 100% of billed charges
  7. Medicare multiple-surgery reduction — pays 100/50%
  8. custom SQL — Single-code override: for CPT V2785 (corneal tissue processing), pay the billed charge in full instead of running normal pricing.
Blue-Cross-MA-ASC-20202 base · 8 adj
Blue Cross MA
Facility · Hospital/ASC · 2020-01-01 → 2022-12-31
Base terms — first match wins
  1. custom SQL — A cosmetic/no-charge carve-out override: for charges whose extracted code fields flag them as 'no charge' (CS='NC'), cosmetic (CT like COS/S9999MN), or specific vision codes (V2786F/V2787F/V27878F), it returns the billed charge as-is (or zero when the billed charge is itself zero) instead of running normal fee-schedule pricing.
  2. 101.8% of the EAPG-Rates fee schedule ⚠︎ named “100% of Blue Cross MA EAPG Rates + 1.8% MN Care Tax” but configured at 101.8%
Adjustments — all apply, in order
  1. modifier 1 present → 0% of the running amount
  2. modifier Y present → 0% of the running amount
  3. modifier 50 present → 150% of the running amount
  4. modifier 52 present → 90% of the running amount
  5. modifier 78 present → 90% of the running amount
  6. cap each charge and the account total at 100% of billed charges
  7. Medicare multiple-surgery reduction — pays 100/50%
  8. custom SQL — Single-code override: for CPT V2785 (corneal tissue processing), pay the billed charge in full instead of running normal pricing.
Blue-Cross-MA-ASC-20232 base · 8 adj
Blue Cross MA
Facility · Minnesota Eye Consultants, Minnesota Eye Laser And Surgery Centers, Minnesota Retina Associates, Northwest Eye Clinic, Southwest Eye Care, Hospital/ASC · 2023-01-01 → 2023-12-31
Base terms — first match wins
  1. custom SQL — A cosmetic/no-charge carve-out override: for charges whose extracted code fields flag them as 'no charge' (CS='NC'), cosmetic (CT like COS/S9999MN), or specific vision codes (V2786F/V2787F/V27878F), it returns the billed charge as-is (or zero when the billed charge is itself zero) instead of running normal fee-schedule pricing.
  2. 101.6% of the EAPG-Rates fee schedule ⚠︎ named “100% of Blue Cross MA EAPG Rates + 1.6% MN Care Tax” but configured at 101.6%
Adjustments — all apply, in order
  1. modifier 1 present → 0% of the running amount
  2. modifier Y present → 0% of the running amount
  3. modifier 50 present → 150% of the running amount
  4. modifier 52 present → 90% of the running amount
  5. modifier 78 present → 90% of the running amount
  6. cap each charge and the account total at 100% of billed charges
  7. Medicare multiple-surgery reduction — pays 100/50%
  8. custom SQL — Single-code override: for CPT V2785 (corneal tissue processing), pay the billed charge in full instead of running normal pricing.
Blue-Cross-MA-ASC-20244 base · 8 adj
Blue Cross MA
Facility · Minnesota Eye Consultants, Minnesota Eye Laser And Surgery Centers, Minnesota Retina Associates, Northwest Eye Clinic, Southwest Eye Care, Hospital/ASC · 2024-01-01 → 2099-12-31
Base terms — first match wins
  1. custom SQL — A cosmetic/no-charge carve-out override: for charges whose extracted code fields flag them as 'no charge' (CS='NC'), cosmetic (CT like COS/S9999MN), or specific vision codes (V2786F/V2787F/V27878F), it returns the billed charge as-is (or zero when the billed charge is itself zero) instead of running normal fee-schedule pricing.
  2. 101.8% of the BC-Carve-Outs fee schedule ⚠︎ named “100% of BC Commercial Fees + 1.8% MN Care Tax” but configured at 101.8%
  3. 100% of billed charges — when ProcCodeFilter V2785 is present
  4. 25% of billed charges
Adjustments — all apply, in order
  1. modifier 1 present → 0% of the running amount
  2. modifier Y present → 0% of the running amount
  3. modifier 50 present → 150% of the running amount
  4. modifier 52 present → 90% of the running amount
  5. modifier 78 present → 90% of the running amount
  6. Medicare multiple-surgery reduction — pays 100/50%
  7. Medicare multiple-procedure reduction — base codes 2, 3; pays 100/50%
  8. cap each charge and the account total at 100% of billed charges
Blue-Cross-Medicare9 base · 17 adj
Blue Cross Medicare
Profee · all facilities · 2016-01-01 → 2099-12-31
Base terms — first match wins
  1. 0% of the Non-Covered-Services fee schedule
  2. custom SQL — A cosmetic/no-charge carve-out override: for charges whose extracted code fields flag them as 'no charge' (CS='NC'), cosmetic (CT like COS/S9999MN), or specific vision codes (V2786F/V2787F/V27878F), it returns the billed charge as-is (or zero when the billed charge is itself zero) instead of running normal fee-schedule pricing.
  3. 100% of the Medicare-Contractor-Codes fee schedule
  4. 100% of the Medicare-Exceptions fee schedule
  5. 100% of Medicare drug
  6. 100% of Medicare lab
  7. 100% of Medicare DME
  8. 100% of Medicare RVU
  9. 100% of the Medicare-MPFSP fee schedule
Adjustments — all apply, in order
  1. modifier 1 present → 0% of the running amount
  2. modifier Y present → 0% of the running amount
  3. Medicare multiple-endoscopy reduction
  4. rescale by a percentage read from the Mid-Level-Charges schedule — when MidLevelProviders Mid-Level is present
  5. modifier 22 present → 135% of the running amount
  6. modifier 25 present → 50% of the running amount
  7. modifier 50 present → 150% of the running amount
  8. modifier 52 present → 90% of the running amount
  9. modifier 54 present → 80% of the running amount
  10. modifier 62 present → 62.5% of the running amount
  11. modifier 78 present → 70% of the running amount
  12. modifier 80 present → 16% of the running amount
  13. modifier 81 present → 16% of the running amount
  14. modifier 82 present → 16% of the running amount
  15. modifier AS present → 13.6% of the running amount
  16. cap each charge and the account total at 100% of billed charges
  17. Medicare multiple-procedure reduction — base codes 2, 3; pays 100/50%
Blue-Cross-Medicare-ASC4 base · 8 adj
Blue Cross Medicare
Facility · Hospital/ASC · 2016-01-01 → 2020-12-31
Base terms — first match wins
  1. 0% of the Non-Covered-Services fee schedule
  2. custom SQL — A cosmetic/no-charge carve-out override: for charges whose extracted code fields flag them as 'no charge' (CS='NC'), cosmetic (CT like COS/S9999MN), or specific vision codes (V2786F/V2787F/V27878F), it returns the billed charge as-is (or zero when the billed charge is itself zero) instead of running normal fee-schedule pricing.
  3. custom SQL — Single-code override, functionally identical to hash 8f8e9be6eea48e6c: for CPT V2785, pay the billed charge in full instead of running normal pricing (with an explicit decimal cast).
  4. 100% of Medicare ASC
Adjustments — all apply, in order
  1. custom SQL — Duplicate of idx31/idx45: pays compounded ophthalmic drug J1097 at full billed charges for dates of service on/after 1/1/2019.
  2. modifier 1 present → 0% of the running amount
  3. modifier Y present → 0% of the running amount
  4. Medicare multiple-endoscopy reduction
  5. modifier 50 present → 150% of the running amount
  6. modifier 52 present → 90% of the running amount
  7. cap each charge and the account total at 100% of billed charges
  8. Medicare multiple-surgery reduction — pays 100/50%
Blue-Cross-Medicare-ASC-20214 base · 9 adj
Blue Cross Medicare
Facility · Minnesota Eye Consultants, Minnesota Eye Laser And Surgery Centers, Minnesota Retina Associates, Northwest Eye Clinic, Southwest Eye Care, Hospital/ASC · 2021-01-01 → 2099-12-31
Base terms — first match wins
  1. 0% of the Non-Covered-Services fee schedule
  2. custom SQL — A cosmetic/no-charge carve-out override: for charges whose extracted code fields flag them as 'no charge' (CS='NC'), cosmetic (CT like COS/S9999MN), or specific vision codes (V2786F/V2787F/V27878F), it returns the billed charge as-is (or zero when the billed charge is itself zero) instead of running normal fee-schedule pricing.
  3. custom SQL — Single-code override, functionally identical to hash 8f8e9be6eea48e6c: for CPT V2785, pay the billed charge in full instead of running normal pricing (with an explicit decimal cast).
  4. 102% of Medicare ASC
Adjustments — all apply, in order
  1. custom SQL — Pays the compounded ophthalmic drug J1097 at full billed charges for dates of service on/after 1/1/2019 (a drug not otherwise represented on a standard fee schedule).
  2. modifier 1 present → 0% of the running amount
  3. modifier Y present → 0% of the running amount
  4. Medicare multiple-endoscopy reduction
  5. modifier 50 present → 150% of the running amount
  6. modifier 52 present → 90% of the running amount
  7. modifier 25 present → 50% of the running amount
  8. cap each charge and the account total at 100% of billed charges
  9. Medicare multiple-surgery reduction — pays 100/50%
Blue-Cross-Medicare-BackUp 9 base · 16 adj
Blue Cross Medicare
Profee · all facilities · 2016-01-01 → 2099-12-31
Base terms — first match wins
  1. 0% of the Non-Covered-Services fee schedule
  2. custom SQL — Cosmetic/no-charge carve-out override, same family as hash ca6756740e819542 (index 2) but missing that snippet's fourth block for the specific V27xx vision codes: pays full billed charge for 'NC' or cosmetic (COS/S9999MN) coded lines, zeroing cosmetic lines with $0 charge.
  3. 100% of the Medicare-Contractor-Codes fee schedule
  4. 100% of the Medicare-Exceptions fee schedule
  5. 100% of the Medicare-Drug fee schedule
  6. 100% of the Medicare-Lab fee schedule
  7. 100% of the Medicare-DME fee schedule
  8. custom SQL — A flat fee-schedule lookup labeled 'Medicare-RVU-Hospital'/'Medicare-RVU-Clinic' that selects a schedule row by facility type, returning fee * Units — despite the name, this does not compute an actual Medicare RVU price, it's a plain customer-maintained fee schedule.
  9. 100% of the Medicare-ASC fee schedule
Adjustments — all apply, in order
  1. modifier 1 present → 0% of the running amount
  2. modifier Y present → 0% of the running amount
  3. multiple-endoscopy reduction (contract rules)
  4. rescale by a percentage read from the Mid-Level-Charges schedule — when MidLevelProviders Mid-Level is present
  5. modifier 22 present → 135% of the running amount
  6. modifier 50 present → 150% of the running amount
  7. modifier 52 present → 90% of the running amount
  8. modifier 54 present → 80% of the running amount
  9. modifier 62 present → 62.5% of the running amount
  10. modifier 78 present → 70% of the running amount
  11. modifier 80 present → 16% of the running amount
  12. modifier 81 present → 16% of the running amount
  13. modifier 82 present → 16% of the running amount
  14. modifier AS present → 13.6% of the running amount
  15. cap each charge and the account total at 100% of billed charges
  16. multiple-procedure reduction (contract rules) — base codes 2, 3; pays 100/50%
Charges-Facility1 base · 0 adj
Charges
Facility · Hospital/ASC · 2016-01-01 → 2099-12-31
Base terms — first match wins
  1. 100% of the ChargeMaster-ASC fee schedule
Charges-Profee1 base · 0 adj
Charges
Profee · all facilities · 2016-01-01 → 2099-12-31
Base terms — first match wins
  1. 100% of the ChargeMaster-Profee fee schedule
First-Health8 base · 5 adj
Aetna, First Health
Profee · Minnesota Eye Consultants, Minnesota Eye Laser And Surgery Centers, Minnesota Retina Associates, Northwest Eye Clinic, Southwest Eye Care · 2023-03-01 → 2023-12-31
Base terms — first match wins
  1. 0% of the Non-Covered-Services fee schedule
  2. custom SQL — A cosmetic/no-charge carve-out override: for charges whose extracted code fields flag them as 'no charge' (CS='NC'), cosmetic (CT like COS/S9999MN), or specific vision codes (V2786F/V2787F/V27878F), it returns the billed charge as-is (or zero when the billed charge is itself zero) instead of running normal fee-schedule pricing.
  3. 210% of Medicare drug
  4. 210% of Medicare lab
  5. 210% of Medicare DME
  6. 210% of Medicare RVU
  7. 210% of Medicare RVU
  8. flat $0
Adjustments — all apply, in order
  1. Medicare multiple-procedure reduction — base codes 2, 3; pays 100/50%
  2. mid-level provider reduction (by NUCC taxonomy)
  3. modifier 50 present → 150% of the running amount
  4. modifier 54 present → 80% of the running amount
  5. cap each charge and the account total at 100% of billed charges
First-Health-20248 base · 5 adj
Aetna, First Health
Profee · Minnesota Eye Consultants, Minnesota Eye Laser And Surgery Centers, Minnesota Retina Associates, Northwest Eye Clinic, Southwest Eye Care · 2024-01-01 → 2099-12-31
Curative
Profee · Minnesota Eye Consultants, Minnesota Eye Laser And Surgery Centers, Minnesota Retina Associates, Northwest Eye Clinic, Southwest Eye Care · 2025-01-01 → 2025-12-31
Base terms — first match wins
  1. 0% of the Non-Covered-Services fee schedule
  2. custom SQL — A cosmetic/no-charge carve-out override: for charges whose extracted code fields flag them as 'no charge' (CS='NC'), cosmetic (CT like COS/S9999MN), or specific vision codes (V2786F/V2787F/V27878F), it returns the billed charge as-is (or zero when the billed charge is itself zero) instead of running normal fee-schedule pricing.
  3. flat $2610 — when ProcCodeFilter 0402T is present
  4. 210% of Medicare drug
  5. 210% of Medicare lab
  6. 210% of Medicare DME
  7. 210% of Medicare RVU
  8. flat $0
Adjustments — all apply, in order
  1. Medicare multiple-procedure reduction — base codes 2, 3; pays 100/50%
  2. mid-level provider reduction (by NUCC taxonomy)
  3. modifier 50 present → 150% of the running amount
  4. modifier 54 present → 80% of the running amount
  5. cap each charge and the account total at 100% of billed charges
First-Health-ASC8 base · 5 adj
Aetna, First Health
Facility · Hospital/ASC · 2023-03-01 → 2023-12-31
Base terms — first match wins
  1. 0% of the Non-Covered-Services fee schedule
  2. custom SQL — A cosmetic/no-charge carve-out override: for charges whose extracted code fields flag them as 'no charge' (CS='NC'), cosmetic (CT like COS/S9999MN), or specific vision codes (V2786F/V2787F/V27878F), it returns the billed charge as-is (or zero when the billed charge is itself zero) instead of running normal fee-schedule pricing.
  3. 210% of Medicare drug
  4. 210% of Medicare lab
  5. 210% of Medicare DME
  6. 210% of Medicare RVU
  7. 210% of Medicare ASC
  8. flat $0
Adjustments — all apply, in order
  1. Medicare multiple-procedure reduction — base codes 2; pays 100/50%
  2. mid-level provider reduction (by NUCC taxonomy)
  3. modifier 50 present → 150% of the running amount
  4. modifier 54 present → 70% of the running amount
  5. cap each charge and the account total at 100% of billed charges
First-Health-ASC-20247 base · 5 adj
Aetna, First Health
Facility · Hospital/ASC · 2024-01-01 → 2099-12-31
Curative
Facility · Hospital/ASC · 2025-01-01 → 2025-12-31
Base terms — first match wins
  1. 0% of the Non-Covered-Services fee schedule
  2. custom SQL — A cosmetic/no-charge carve-out override: for charges whose extracted code fields flag them as 'no charge' (CS='NC'), cosmetic (CT like COS/S9999MN), or specific vision codes (V2786F/V2787F/V27878F), it returns the billed charge as-is (or zero when the billed charge is itself zero) instead of running normal fee-schedule pricing.
  3. 210% of Medicare drug
  4. 210% of Medicare lab
  5. 210% of Medicare DME
  6. 210% of Medicare ASC
  7. flat $0
Adjustments — all apply, in order
  1. Medicare multiple-procedure reduction — base codes 2; pays 100/50%
  2. mid-level provider reduction (by NUCC taxonomy)
  3. modifier 50 present → 150% of the running amount
  4. modifier 54 present → 70% of the running amount
  5. cap each charge and the account total at 100% of billed charges
HealthPartners3 base · 10 adj
Cigna, GreatWest/Cigna, HealthPartners
Profee · Minnesota Eye Consultants, Minnesota Eye Laser And Surgery Centers, Minnesota Retina Associates, Northwest Eye Clinic · 2017-01-01 → 2022-12-31
Base terms — first match wins
  1. 100% of billed charges — when CoverageStatus NC is present
  2. custom SQL — Same Profee fee-schedule lookup as idx32/36/37, with an extra flat 2% markup baked directly into the query (*1.02).
  3. 70% of billed charges
Adjustments — all apply, in order
  1. modifier 1 present → 0% of the running amount
  2. modifier Y present → 0% of the running amount
  3. rescale by a percentage read from the Mid-Level-Charges schedule — when MidLevelProviders Mid-Level is present
  4. modifier 25 present → 80% of the running amount
  5. modifier 50 present → 200% of the running amount
  6. modifier 52 present → 50% of the running amount
  7. modifier 54 present → 70% of the running amount
  8. Medicare multiple-procedure reduction — base codes 2, 3; pays 100/50%
  9. modifier 50 present → 75% of the running amount
  10. cap each charge and the account total at 100% of billed charges
HealthPartners-20164 base · 9 adj
Cigna, GreatWest/Cigna, HealthPartners
Profee · Minnesota Eye Consultants, Minnesota Eye Laser And Surgery Centers, Minnesota Retina Associates, Northwest Eye Clinic · 2016-01-01 → 2016-12-31
Base terms — first match wins
  1. custom SQL — A cosmetic/no-charge carve-out override: for charges whose extracted code fields flag them as 'no charge' (CS='NC'), cosmetic (CT like COS/S9999MN), or specific vision codes (V2786F/V2787F/V27878F), it returns the billed charge as-is (or zero when the billed charge is itself zero) instead of running normal fee-schedule pricing.
  2. custom SQL — Same Profee-style fee lookup pattern as sql_hash 4f7320fe47f9e781/58bcd5165b3e94a2, applied against Optometry-Hospital/Optometry-Clinic schedules instead, with a 1.02 uplift. — when Optometrist Optometrist is present
  3. custom SQL — Same Profee fee-schedule lookup as idx32/36/37, with an extra flat 2% markup baked directly into the query (*1.02).
  4. 70% of billed charges
Adjustments — all apply, in order
  1. modifier 1 present → 0% of the running amount
  2. modifier Y present → 0% of the running amount
  3. rescale by a percentage read from the Mid-Level-Charges schedule — when MidLevelProviders Mid-Level is present
  4. modifier 25 present → 80% of the running amount
  5. modifier 50 present → 150% of the running amount
  6. modifier 52 present → 50% of the running amount
  7. modifier 54 present → 70% of the running amount
  8. Medicare multiple-procedure reduction — base codes 2, 3; pays 100/50%
  9. cap each charge and the account total at 100% of billed charges
HealthPartners-20235 base · 9 adj
Cigna, GreatWest/Cigna, Healthgram, HealthPartners
Profee · Minnesota Eye Consultants, Minnesota Eye Laser And Surgery Centers, Minnesota Retina Associates, Northwest Eye Clinic · 2023-01-01 → 2024-12-31
Base terms — first match wins
  1. 100% of billed charges — when CoverageStatus NC is present
  2. custom SQL — A cosmetic/no-charge carve-out override: for charges whose extracted code fields flag them as 'no charge' (CS='NC'), cosmetic (CT like COS/S9999MN), or specific vision codes (V2786F/V2787F/V27878F), it returns the billed charge as-is (or zero when the billed charge is itself zero) instead of running normal fee-schedule pricing.
  3. 100% of the Profee-Clinic-ProcCode fee schedule — when PlaceOfService 11 is present
  4. 100% of the Profee-Hospital-ProcCode fee schedule — when PlaceOfService 11 is absent
  5. 70% of billed charges
Adjustments — all apply, in order
  1. modifier 1 present → 0% of the running amount
  2. modifier Y present → 0% of the running amount
  3. modifier 50 present → 200% of the running amount
  4. modifier 52 present → 50% of the running amount
  5. modifier 54 present → 70% of the running amount
  6. Medicare multiple-procedure reduction — base codes 2, 3; pays 100/50%
  7. modifier 50 present → 75% of the running amount
  8. mid-level provider reduction (by NUCC taxonomy)
  9. cap each charge and the account total at 100% of billed charges
HealthPartners-20255 base · 8 adj
Cigna, GreatWest/Cigna, Healthgram, HealthPartners
Profee · Minnesota Eye Consultants, Minnesota Eye Laser And Surgery Centers, Minnesota Retina Associates, Northwest Eye Clinic · 2025-01-01 → 2099-12-31
Curative
Profee · Minnesota Eye Consultants, Minnesota Eye Laser And Surgery Centers, Minnesota Retina Associates, Northwest Eye Clinic · 2026-01-01 → 2099-12-31
Base terms — first match wins
  1. 100% of billed charges — when CoverageStatus NC is present
  2. custom SQL — A cosmetic/no-charge carve-out override: for charges whose extracted code fields flag them as 'no charge' (CS='NC'), cosmetic (CT like COS/S9999MN), or specific vision codes (V2786F/V2787F/V27878F), it returns the billed charge as-is (or zero when the billed charge is itself zero) instead of running normal fee-schedule pricing.
  3. 101.8% of the Profee-Clinic-ProcCode fee schedule — when PlaceOfService 11 is present ⚠︎ named “100% of Fees + MN CARE TAX .018%” but configured at 101.8%
  4. 101.8% of the Profee-Hospital-ProcCode fee schedule — when PlaceOfService 11 is absent ⚠︎ named “100% of Fees + MN CARE TAX .018%” but configured at 101.8%
  5. 70% of billed charges
Adjustments — all apply, in order
  1. modifier 1 present → 0% of the running amount
  2. modifier Y present → 0% of the running amount
  3. modifier 50 present → 150% of the running amount
  4. modifier 52 present → 50% of the running amount
  5. modifier 54 present → 70% of the running amount
  6. Medicare multiple-procedure reduction — base codes 2, 3; pays 100/50%
  7. mid-level provider reduction (by NUCC taxonomy)
  8. cap each charge and the account total at 100% of billed charges
HealthPartners-ASC2 base · 11 adj
Cigna, GreatWest/Cigna, HealthPartners
Facility · Hospital/ASC · 2016-01-01 → 2019-12-31
Base terms — first match wins
  1. custom SQL — A cosmetic/no-charge carve-out override: for charges whose extracted code fields flag them as 'no charge' (CS='NC'), cosmetic (CT like COS/S9999MN), or specific vision codes (V2786F/V2787F/V27878F), it returns the billed charge as-is (or zero when the billed charge is itself zero) instead of running normal fee-schedule pricing.
  2. 102% of the APC-Rates fee schedule ⚠︎ named “100% of HP APC Rates + 2% MN Care Tax” but configured at 102%
Adjustments — all apply, in order
  1. modifier 1 present → 0% of the running amount
  2. modifier Y present → 0% of the running amount
  3. zero out charges excluded by the Bundled-Procedures schedule
  4. modifier 25 present → 80% of the running amount
  5. modifier 50 present → 150% of the running amount
  6. modifier 52 present → 50% of the running amount
  7. modifier 54 present → 70% of the running amount
  8. cap each charge and the account total at 100% of billed charges
  9. Medicare multiple-surgery reduction — pays 100/50%
  10. multiple-surgery reduction (contract rules) — pays 100/0%
  11. custom SQL — Pays a fixed, date-tiered flat fee (with a 2% markup applied via *1.02) for procedure V2785 (corneal donor tissue/processing), stepping the base fee from $3850 to $4050 (4/1/2017) to $4300 (4/1/2019).
HealthPartners-ASC-20202 base · 11 adj
Cigna, GreatWest/Cigna, HealthPartners
Facility · Hospital/ASC · 2020-01-01 → 2022-12-31
Base terms — first match wins
  1. custom SQL — A cosmetic/no-charge carve-out override: for charges whose extracted code fields flag them as 'no charge' (CS='NC'), cosmetic (CT like COS/S9999MN), or specific vision codes (V2786F/V2787F/V27878F), it returns the billed charge as-is (or zero when the billed charge is itself zero) instead of running normal fee-schedule pricing.
  2. 101.8% of the APC-Rates fee schedule ⚠︎ named “100% of HP APC Rates + 1.8% MN Care Tax” but configured at 101.8%
Adjustments — all apply, in order
  1. modifier 1 present → 0% of the running amount
  2. modifier Y present → 0% of the running amount
  3. zero out charges excluded by the Bundled-Procedures schedule
  4. modifier 25 present → 80% of the running amount
  5. modifier 50 present → 150% of the running amount
  6. modifier 52 present → 50% of the running amount
  7. modifier 54 present → 70% of the running amount
  8. cap each charge and the account total at 100% of billed charges
  9. Medicare multiple-surgery reduction — pays 100/50%
  10. multiple-surgery reduction (contract rules) — pays 100/0%
  11. custom SQL — Overrides the allowed amount for contact-lens code V2785 to a flat, date-tiered fee (pre-2017: $3850, 2017-2019: $4050, post-2019: $4300, each x1.018); leaves every other code's amount untouched.
HealthPartners-ASC-20232 base · 11 adj
Cigna, GreatWest/Cigna, Healthgram, HealthPartners
Facility · Hospital/ASC · 2023-01-01 → 2023-12-31
Base terms — first match wins
  1. custom SQL — A cosmetic/no-charge carve-out override: for charges whose extracted code fields flag them as 'no charge' (CS='NC'), cosmetic (CT like COS/S9999MN), or specific vision codes (V2786F/V2787F/V27878F), it returns the billed charge as-is (or zero when the billed charge is itself zero) instead of running normal fee-schedule pricing.
  2. 101.6% of the APC-Rates fee schedule ⚠︎ named “100% of HP APC Rates + 1.6% MN Care Tax” but configured at 101.6%
Adjustments — all apply, in order
  1. modifier 1 present → 0% of the running amount
  2. modifier Y present → 0% of the running amount
  3. zero out charges excluded by the Bundled-Procedures schedule
  4. modifier 25 present → 80% of the running amount
  5. modifier 50 present → 150% of the running amount
  6. modifier 52 present → 50% of the running amount
  7. modifier 54 present → 70% of the running amount
  8. cap each charge and the account total at 100% of billed charges
  9. Medicare multiple-surgery reduction — pays 100/50%
  10. multiple-surgery reduction (contract rules) — pays 100/0%
  11. custom SQL — Hardcodes a fixed, inflation-adjusted (x1.018) dollar amount for CPT V2785 across five contract-effective date tiers (3850, 4050, 4400, 5250, 5470), defaulting to 4300 for any other date.
HealthPartners-ASC-20242 base · 12 adj
Cigna, GreatWest/Cigna, Healthgram, HealthPartners
Facility · Hospital/ASC · 2024-01-01 → 2025-05-31
Base terms — first match wins
  1. custom SQL — A cosmetic/no-charge carve-out override: for charges whose extracted code fields flag them as 'no charge' (CS='NC'), cosmetic (CT like COS/S9999MN), or specific vision codes (V2786F/V2787F/V27878F), it returns the billed charge as-is (or zero when the billed charge is itself zero) instead of running normal fee-schedule pricing.
  2. 101.8% of the APC-Rates fee schedule ⚠︎ named “100% of HP APC Rates + 1.8% MN Care Tax” but configured at 101.8%
Adjustments — all apply, in order
  1. modifier 1 present → 0% of the running amount
  2. modifier Y present → 0% of the running amount
  3. zero out charges excluded by the Bundled-Procedures schedule
  4. modifier 25 present → 80% of the running amount
  5. modifier 50 present → 150% of the running amount
  6. modifier 52 present → 50% of the running amount
  7. modifier 54 present → 70% of the running amount
  8. cap each charge and the account total at 100% of billed charges
  9. Medicare multiple-surgery reduction — pays 100/50%
  10. multiple-surgery reduction (contract rules) — pays 100/0%
  11. custom SQL — Same V2785 contact-lens date-tiered flat fee as the prior snippet, extended with a 2023-01-01 to 2024-05-31 tier ($4400) and two commented-out future tiers (mid-2024, 2025) not yet enabled; for dates after the last active tier, explicitly falls back to leaving the current {Allowed} amount unchanged.
  12. custom SQL — Hardcoded price override for drug HCPCS J1097, effective 6/1/2025: pays a fixed $153.50 x 1.018 inflation-style multiplier, but only for service dates on/after 6/1/2025.
HealthPartners-ASC-20253 base · 13 adj
Cigna, GreatWest/Cigna, Healthgram, HealthPartners
Facility · Hospital/ASC · 2025-06-01 → 2099-12-31
Curative
Facility · Hospital/ASC · 2026-01-01 → 2099-12-31
Base terms — first match wins
  1. custom SQL — A cosmetic/no-charge carve-out override: for charges whose extracted code fields flag them as 'no charge' (CS='NC'), cosmetic (CT like COS/S9999MN), or specific vision codes (V2786F/V2787F/V27878F), it returns the billed charge as-is (or zero when the billed charge is itself zero) instead of running normal fee-schedule pricing.
  2. 101.8% of the Carve-Outs fee schedule
  3. 101.8% of the APC-Rates fee schedule ⚠︎ named “100% of HP APC Rates + 1.8% MN Care Tax” but configured at 101.8%
Adjustments — all apply, in order
  1. modifier 1 present → 0% of the running amount
  2. modifier Y present → 0% of the running amount
  3. zero out charges excluded by the Bundled-Codes schedule
  4. zero out charges excluded by the Bundled-Procedures schedule
  5. modifier 25 present → 80% of the running amount
  6. modifier 50 present → 150% of the running amount
  7. modifier 52 present → 50% of the running amount
  8. modifier 54 present → 70% of the running amount
  9. Medicare multiple-surgery reduction — pays 100/50%
  10. multiple-surgery reduction (contract rules) — pays 100/0%
  11. custom SQL — Hardcodes a fixed, inflation-adjusted (x1.018) dollar amount for CPT V2785 across contract-effective date tiers (3850, 4050, 4400), falling back to the charge's existing {Allowed} amount for any date not in those three tiers.
  12. custom SQL — Hardcoded price override for drug HCPCS J1097, effective 6/1/2025: pays a fixed $153.50 x 1.018 inflation-style multiplier, but only for service dates on/after 6/1/2025.
  13. cap each charge and the account total at 100% of billed charges
HealthPartners-FEP3 base · 9 adj
HealthPartners FEP
Profee · Minnesota Eye Consultants, Minnesota Eye Laser And Surgery Centers, Minnesota Retina Associates, Northwest Eye Clinic · 2017-01-01 → 2022-12-31
Base terms — first match wins
  1. custom SQL — A cosmetic/no-charge carve-out override: for charges whose extracted code fields flag them as 'no charge' (CS='NC'), cosmetic (CT like COS/S9999MN), or specific vision codes (V2786F/V2787F/V27878F), it returns the billed charge as-is (or zero when the billed charge is itself zero) instead of running normal fee-schedule pricing.
  2. custom SQL — Professional-fee ('Profee') schedule lookup that selects between 'Profee-Hospital' and 'Profee-Clinic' schedules based on the charge's place-of-service, returning the matching fee * Units.
  3. 70% of billed charges
Adjustments — all apply, in order
  1. modifier 1 present → 0% of the running amount
  2. modifier Y present → 0% of the running amount
  3. rescale by a percentage read from the Mid-Level-Charges schedule — when MidLevelProviders Mid-Level is present
  4. modifier 25 present → 80% of the running amount
  5. modifier 50 present → 150% of the running amount
  6. modifier 52 present → 50% of the running amount
  7. modifier 54 present → 70% of the running amount
  8. Medicare multiple-procedure reduction — base codes 2, 3; pays 100/50%
  9. cap each charge and the account total at 100% of billed charges
HealthPartners-FEP-20164 base · 9 adj
HealthPartners FEP
Profee · Minnesota Eye Consultants, Minnesota Eye Laser And Surgery Centers, Minnesota Retina Associates, Northwest Eye Clinic · 2016-01-01 → 2016-12-31
Base terms — first match wins
  1. custom SQL — A cosmetic/no-charge carve-out override: for charges whose extracted code fields flag them as 'no charge' (CS='NC'), cosmetic (CT like COS/S9999MN), or specific vision codes (V2786F/V2787F/V27878F), it returns the billed charge as-is (or zero when the billed charge is itself zero) instead of running normal fee-schedule pricing.
  2. custom SQL — Optometry fee-schedule lookup: same Profee-style pattern as 171/182 (highest-priority row via POS-code-indicator crosswalk) but against Optometry-Hospital/Optometry-Clinic schedule types, with no extra inflation multiplier, just Units. — when Optometrist Optometrist is present
  3. custom SQL — Professional-fee ('Profee') schedule lookup that selects between 'Profee-Hospital' and 'Profee-Clinic' schedules based on the charge's place-of-service, returning the matching fee * Units.
  4. 70% of billed charges
Adjustments — all apply, in order
  1. modifier 1 present → 0% of the running amount
  2. modifier Y present → 0% of the running amount
  3. rescale by a percentage read from the Mid-Level-Charges schedule — when MidLevelProviders Mid-Level is present
  4. modifier 25 present → 80% of the running amount
  5. modifier 50 present → 150% of the running amount
  6. modifier 52 present → 50% of the running amount
  7. modifier 54 present → 70% of the running amount
  8. Medicare multiple-procedure reduction — base codes 2, 3; pays 100/50%
  9. cap each charge and the account total at 100% of billed charges
HealthPartners-FEP-20234 base · 8 adj
HealthPartners FEP
Profee · Minnesota Eye Consultants, Minnesota Eye Laser And Surgery Centers, Minnesota Retina Associates, Northwest Eye Clinic · 2023-01-01 → 2099-12-31
Base terms — first match wins
  1. custom SQL — A cosmetic/no-charge carve-out override: for charges whose extracted code fields flag them as 'no charge' (CS='NC'), cosmetic (CT like COS/S9999MN), or specific vision codes (V2786F/V2787F/V27878F), it returns the billed charge as-is (or zero when the billed charge is itself zero) instead of running normal fee-schedule pricing.
  2. 100% of the Profee-Clinic-ProcCode fee schedule — when PlaceOfService 11 is present
  3. 100% of the Profee-Hospital-ProcCode fee schedule — when PlaceOfService 11 is absent
  4. 70% of billed charges
Adjustments — all apply, in order
  1. modifier 1 present → 0% of the running amount
  2. modifier Y present → 0% of the running amount
  3. modifier 50 present → 150% of the running amount
  4. modifier 52 present → 50% of the running amount
  5. modifier 54 present → 70% of the running amount
  6. Medicare multiple-procedure reduction — base codes 2, 3; pays 100/50%
  7. custom SQL — Applies a flat 15% discount to the already-computed allowed amount whenever the rendering provider's specialty (looked up by ProviderID) is 'Primary Care'.
  8. cap each charge and the account total at 100% of billed charges
HealthPartners-FEP-ASC2 base · 12 adj
HealthPartners FEP
Facility · Hospital/ASC · 2016-01-01 → 2025-05-31
Base terms — first match wins
  1. custom SQL — A cosmetic/no-charge carve-out override: for charges whose extracted code fields flag them as 'no charge' (CS='NC'), cosmetic (CT like COS/S9999MN), or specific vision codes (V2786F/V2787F/V27878F), it returns the billed charge as-is (or zero when the billed charge is itself zero) instead of running normal fee-schedule pricing.
  2. 100% of the APC-Rates fee schedule
Adjustments — all apply, in order
  1. modifier 1 present → 0% of the running amount
  2. modifier Y present → 0% of the running amount
  3. zero out charges excluded by the Bundled-Procedures schedule
  4. modifier 25 present → 80% of the running amount
  5. modifier 50 present → 150% of the running amount
  6. modifier 52 present → 50% of the running amount
  7. modifier 54 present → 70% of the running amount
  8. cap each charge and the account total at 100% of billed charges
  9. Medicare multiple-surgery reduction — pays 100/50%
  10. multiple-surgery reduction (contract rules) — pays 100/0%
  11. custom SQL — Hardcodes a fixed dollar allowed amount for CPT V2785 (corneal tissue processing) that steps up across several contract-effective dates (3850 -> 4050 -> 4400 -> 5250 -> 5470, defaulting to 4300 for any other date); every other code is left unadjusted.
  12. custom SQL — Hardcoded flat fee of $153.50 for HCPCS J1097 (bimatoprost implant) for dates of service on/after 2025-06-01.
HealthPartners-FEP-ASC-20253 base · 13 adj
HealthPartners FEP
Facility · Hospital/ASC · 2025-06-01 → 2099-12-31
Base terms — first match wins
  1. custom SQL — A cosmetic/no-charge carve-out override: for charges whose extracted code fields flag them as 'no charge' (CS='NC'), cosmetic (CT like COS/S9999MN), or specific vision codes (V2786F/V2787F/V27878F), it returns the billed charge as-is (or zero when the billed charge is itself zero) instead of running normal fee-schedule pricing.
  2. 100% of the Carve-Outs fee schedule
  3. 100% of the APC-Rates fee schedule
Adjustments — all apply, in order
  1. modifier 1 present → 0% of the running amount
  2. modifier Y present → 0% of the running amount
  3. zero out charges excluded by the Bundled-Procedures schedule
  4. zero out charges excluded by the Bundled-Codes schedule
  5. modifier 25 present → 80% of the running amount
  6. modifier 50 present → 150% of the running amount
  7. modifier 52 present → 50% of the running amount
  8. modifier 54 present → 70% of the running amount
  9. cap each charge and the account total at 100% of billed charges
  10. Medicare multiple-surgery reduction — pays 100/50%
  11. multiple-surgery reduction (contract rules) — pays 100/0%
  12. custom SQL — Hardcodes a tiered flat price for HCPCS V2785 (corneal tissue processing) by date band: $3,850 before 4/1/2017, $4,050 from 4/1/2017–3/31/2019, and $4,400 for a 2023–2024 window added by a later ticket.
  13. custom SQL — Hardcoded flat fee of $153.50 for HCPCS J1097 (bimatoprost implant) for dates of service on/after 2025-06-01.
HealthPartners-FEP-UVP-Profee3 base · 9 adj
HealthPartners FEP
Profee · Southwest Eye Care · 2025-01-01 → 2099-12-31
Base terms — first match wins
  1. custom SQL — A cosmetic/no-charge carve-out override: for charges whose extracted code fields flag them as 'no charge' (CS='NC'), cosmetic (CT like COS/S9999MN), or specific vision codes (V2786F/V2787F/V27878F), it returns the billed charge as-is (or zero when the billed charge is itself zero) instead of running normal fee-schedule pricing.
  2. 100% of the UVP-Profee-Clinic fee schedule — when PlaceOfService 11 is present
  3. 100% of the UVP-Profee-Hospital fee schedule — when PlaceOfService 11 is absent
Adjustments — all apply, in order
  1. modifier 1 present → 0% of the running amount
  2. modifier Y present → 0% of the running amount
  3. rescale by a percentage read from the Mid-Level-Charges schedule — when MidLevelProviders Mid-Level is present
  4. modifier 50 present → 150% of the running amount
  5. modifier 52 present → 50% of the running amount
  6. modifier 54 present → 80% of the running amount
  7. modifier 78 present → 84% of the running amount
  8. Medicare multiple-procedure reduction — base codes 2, 3; pays 100/50%
  9. cap each charge and the account total at 100% of billed charges
HealthPartners-MA-ASC2 base · 11 adj
HealthPartners MA
Facility · Hospital/ASC · 2016-01-01 → 2019-12-31
Base terms — first match wins
  1. custom SQL — A cosmetic/no-charge carve-out override: for charges whose extracted code fields flag them as 'no charge' (CS='NC'), cosmetic (CT like COS/S9999MN), or specific vision codes (V2786F/V2787F/V27878F), it returns the billed charge as-is (or zero when the billed charge is itself zero) instead of running normal fee-schedule pricing.
  2. 102% of the APC-Rates fee schedule ⚠︎ named “100% of HP APC Rates + 2% MN Care Tax” but configured at 102%
Adjustments — all apply, in order
  1. modifier 1 present → 0% of the running amount
  2. modifier Y present → 0% of the running amount
  3. zero out charges excluded by the Bundled-Procedures schedule
  4. modifier 25 present → 80% of the running amount
  5. modifier 50 present → 150% of the running amount
  6. modifier 52 present → 50% of the running amount
  7. modifier 54 present → 70% of the running amount
  8. cap each charge and the account total at 100% of billed charges
  9. Medicare multiple-surgery reduction — pays 100/50%
  10. multiple-surgery reduction (contract rules) — pays 100/0%
  11. custom SQL — Pays a fixed, date-tiered flat fee (with a 2% markup applied via *1.02) for procedure V2785 (corneal donor tissue/processing), stepping the base fee from $3850 to $4050 (4/1/2017) to $4300 (4/1/2019).
HealthPartners-MA-ASC-20202 base · 11 adj
HealthPartners MA
Facility · Hospital/ASC · 2020-01-01 → 2022-12-31
Base terms — first match wins
  1. custom SQL — A cosmetic/no-charge carve-out override: for charges whose extracted code fields flag them as 'no charge' (CS='NC'), cosmetic (CT like COS/S9999MN), or specific vision codes (V2786F/V2787F/V27878F), it returns the billed charge as-is (or zero when the billed charge is itself zero) instead of running normal fee-schedule pricing.
  2. 101.8% of the APC-Rates fee schedule ⚠︎ named “100% of HP APC Rates + 1.8% MN Care Tax” but configured at 101.8%
Adjustments — all apply, in order
  1. modifier 1 present → 0% of the running amount
  2. modifier Y present → 0% of the running amount
  3. zero out charges excluded by the Bundled-Procedures schedule
  4. modifier 25 present → 80% of the running amount
  5. modifier 50 present → 150% of the running amount
  6. modifier 52 present → 50% of the running amount
  7. modifier 54 present → 70% of the running amount
  8. cap each charge and the account total at 100% of billed charges
  9. Medicare multiple-surgery reduction — pays 100/50%
  10. multiple-surgery reduction (contract rules) — pays 100/0%
  11. custom SQL — Pays a fixed, date-tiered flat fee (with a 2% markup applied via *1.02) for procedure V2785 (corneal donor tissue/processing), stepping the base fee from $3850 to $4050 (4/1/2017) to $4300 (4/1/2019).
HealthPartners-MA-ASC-20232 base · 11 adj
HealthPartners MA
Facility · Hospital/ASC · 2023-01-01 → 2023-12-31
Base terms — first match wins
  1. custom SQL — A cosmetic/no-charge carve-out override: for charges whose extracted code fields flag them as 'no charge' (CS='NC'), cosmetic (CT like COS/S9999MN), or specific vision codes (V2786F/V2787F/V27878F), it returns the billed charge as-is (or zero when the billed charge is itself zero) instead of running normal fee-schedule pricing.
  2. 101.6% of the APC-Rates fee schedule ⚠︎ named “100% of HP APC Rates + 1.6% MN Care Tax” but configured at 101.6%
Adjustments — all apply, in order
  1. modifier 1 present → 0% of the running amount
  2. modifier Y present → 0% of the running amount
  3. zero out charges excluded by the Bundled-Procedures schedule
  4. modifier 25 present → 80% of the running amount
  5. modifier 50 present → 150% of the running amount
  6. modifier 52 present → 50% of the running amount
  7. modifier 54 present → 70% of the running amount
  8. cap each charge and the account total at 100% of billed charges
  9. Medicare multiple-surgery reduction — pays 100/50%
  10. multiple-surgery reduction (contract rules) — pays 100/0%
  11. custom SQL — Date-tiered flat fee for HCPCS V2785 (corneal donor tissue/processing) with a 1.8% markup: $3850 before 2017-04-01, $4050 to 2019-04-01, $4400 for 2023-01-01..2024-05-31, $5250 for 2024-06-01..2024-12-31, $5470 from 2025-01-01, else $4300.
HealthPartners-MA-ASC-20242 base · 12 adj
HealthPartners MA
Facility · Minnesota Eye Consultants, Minnesota Eye Laser And Surgery Centers, Minnesota Retina Associates, Northwest Eye Clinic, Southwest Eye Care, Hospital/ASC · 2024-01-01 → 2025-05-31
Base terms — first match wins
  1. custom SQL — A cosmetic/no-charge carve-out override: for charges whose extracted code fields flag them as 'no charge' (CS='NC'), cosmetic (CT like COS/S9999MN), or specific vision codes (V2786F/V2787F/V27878F), it returns the billed charge as-is (or zero when the billed charge is itself zero) instead of running normal fee-schedule pricing.
  2. 101.8% of the APC-Rates fee schedule ⚠︎ named “100% of HP APC Rates + 1.8% MN Care Tax” but configured at 101.8%
Adjustments — all apply, in order
  1. modifier 1 present → 0% of the running amount
  2. modifier Y present → 0% of the running amount
  3. zero out charges excluded by the Bundled-Procedures schedule
  4. modifier 25 present → 80% of the running amount
  5. modifier 50 present → 150% of the running amount
  6. modifier 52 present → 50% of the running amount
  7. modifier 54 present → 70% of the running amount
  8. cap each charge and the account total at 100% of billed charges
  9. Medicare multiple-surgery reduction — pays 100/50%
  10. multiple-surgery reduction (contract rules) — pays 100/0%
  11. custom SQL — Date-tiered flat fee for HCPCS V2785 (corneal donor tissue/processing) with a 1.8% markup: $3850 before 2017-04-01, $4050 to 2019-04-01, $4400 for 2023-01-01..2024-05-31, $5250 for 2024-06-01..2024-12-31, $5470 from 2025-01-01, else $4300.
  12. custom SQL — Hardcoded price override for drug HCPCS J1097, effective 6/1/2025: pays a fixed $153.50 x 1.018 inflation-style multiplier, but only for service dates on/after 6/1/2025.
HealthPartners-MA-ASC-20253 base · 13 adj
HealthPartners MA
Facility · Minnesota Eye Consultants, Minnesota Eye Laser And Surgery Centers, Minnesota Retina Associates, Northwest Eye Clinic, Southwest Eye Care, Hospital/ASC · 2025-06-01 → 2099-12-31
Base terms — first match wins
  1. custom SQL — A cosmetic/no-charge carve-out override: for charges whose extracted code fields flag them as 'no charge' (CS='NC'), cosmetic (CT like COS/S9999MN), or specific vision codes (V2786F/V2787F/V27878F), it returns the billed charge as-is (or zero when the billed charge is itself zero) instead of running normal fee-schedule pricing.
  2. 101.8% of the Carve-Outs fee schedule
  3. 101.8% of the APC-Rates fee schedule ⚠︎ named “100% of HP APC Rates + 1.8% MN Care Tax” but configured at 101.8%
Adjustments — all apply, in order
  1. modifier 1 present → 0% of the running amount
  2. modifier Y present → 0% of the running amount
  3. zero out charges excluded by the Bundled-Procedures schedule
  4. zero out charges excluded by the Bundled-Codes schedule
  5. modifier 25 present → 80% of the running amount
  6. modifier 50 present → 150% of the running amount
  7. modifier 52 present → 50% of the running amount
  8. modifier 54 present → 70% of the running amount
  9. cap each charge and the account total at 100% of billed charges
  10. Medicare multiple-surgery reduction — pays 100/50%
  11. multiple-surgery reduction (contract rules) — pays 100/0%
  12. custom SQL — Functionally identical to bacbf98d17758d43 (same V2785 date-tiered flat fee, same 2023-2024 tier, same commented-out future tiers) — differs only in a trailing comment.
  13. custom SQL — Hardcoded price override for drug HCPCS J1097, effective 6/1/2025: pays a fixed $153.50 x 1.018 inflation-style multiplier, but only for service dates on/after 6/1/2025.
HealthPartners-MSHO3 base · 9 adj
HealthPartners MSHO
Profee · Minnesota Eye Consultants, Minnesota Eye Laser And Surgery Centers · 2016-01-01 → 2099-12-31
Base terms — first match wins
  1. custom SQL — A cosmetic/no-charge carve-out override: for charges whose extracted code fields flag them as 'no charge' (CS='NC'), cosmetic (CT like COS/S9999MN), or specific vision codes (V2786F/V2787F/V27878F), it returns the billed charge as-is (or zero when the billed charge is itself zero) instead of running normal fee-schedule pricing.
  2. custom SQL — Same Profee fee-schedule lookup as idx32/36/37, with an extra flat 2% markup baked directly into the query (*1.02).
  3. 70% of billed charges
Adjustments — all apply, in order
  1. modifier 1 present → 0% of the running amount
  2. modifier Y present → 0% of the running amount
  3. rescale by a percentage read from the Mid-Level-Charges schedule — when MidLevelProviders Mid-Level is present
  4. modifier 25 present → 80% of the running amount
  5. modifier 50 present → 150% of the running amount
  6. modifier 52 present → 50% of the running amount
  7. modifier 54 present → 70% of the running amount
  8. Medicare multiple-procedure reduction — base codes 2, 3; pays 100/50%
  9. cap each charge and the account total at 100% of billed charges
HealthPartners-MSHO-ASC2 base · 11 adj
HealthPartners MSHO
Facility · Hospital/ASC · 2016-01-01 → 2019-12-31
Base terms — first match wins
  1. custom SQL — A cosmetic/no-charge carve-out override: for charges whose extracted code fields flag them as 'no charge' (CS='NC'), cosmetic (CT like COS/S9999MN), or specific vision codes (V2786F/V2787F/V27878F), it returns the billed charge as-is (or zero when the billed charge is itself zero) instead of running normal fee-schedule pricing.
  2. 102% of the APC-Rates fee schedule ⚠︎ named “100% of HP APC Rates + 2% MN Care Tax” but configured at 102%
Adjustments — all apply, in order
  1. modifier 1 present → 0% of the running amount
  2. modifier Y present → 0% of the running amount
  3. zero out charges excluded by the Bundled-Procedures schedule
  4. modifier 25 present → 80% of the running amount
  5. modifier 50 present → 150% of the running amount
  6. modifier 52 present → 50% of the running amount
  7. modifier 54 present → 70% of the running amount
  8. cap each charge and the account total at 100% of billed charges
  9. Medicare multiple-surgery reduction — pays 100/50%
  10. multiple-surgery reduction (contract rules) — pays 100/0%
  11. custom SQL — Pays a fixed, date-tiered flat fee (with a 2% markup applied via *1.02) for procedure V2785 (corneal donor tissue/processing), stepping the base fee from $3850 to $4050 (4/1/2017) to $4300 (4/1/2019).
HealthPartners-MSHO-ASC-20202 base · 11 adj
HealthPartners MSHO
Facility · Hospital/ASC · 2020-01-01 → 2022-12-31
Base terms — first match wins
  1. custom SQL — A cosmetic/no-charge carve-out override: for charges whose extracted code fields flag them as 'no charge' (CS='NC'), cosmetic (CT like COS/S9999MN), or specific vision codes (V2786F/V2787F/V27878F), it returns the billed charge as-is (or zero when the billed charge is itself zero) instead of running normal fee-schedule pricing.
  2. 101.8% of the APC-Rates fee schedule ⚠︎ named “100% of HP APC Rates + 1.8% MN Care Tax” but configured at 101.8%
Adjustments — all apply, in order
  1. modifier 1 present → 0% of the running amount
  2. modifier Y present → 0% of the running amount
  3. zero out charges excluded by the Bundled-Procedures schedule
  4. modifier 25 present → 80% of the running amount
  5. modifier 50 present → 150% of the running amount
  6. modifier 52 present → 50% of the running amount
  7. modifier 54 present → 70% of the running amount
  8. cap each charge and the account total at 100% of billed charges
  9. Medicare multiple-surgery reduction — pays 100/50%
  10. multiple-surgery reduction (contract rules) — pays 100/0%
  11. custom SQL — Pays a fixed, date-tiered flat fee (with a 2% markup applied via *1.02) for procedure V2785 (corneal donor tissue/processing), stepping the base fee from $3850 to $4050 (4/1/2017) to $4300 (4/1/2019).
HealthPartners-MSHO-ASC-20232 base · 11 adj
HealthPartners MSHO
Facility · Hospital/ASC · 2023-01-01 → 2023-12-31
Base terms — first match wins
  1. custom SQL — A cosmetic/no-charge carve-out override: for charges whose extracted code fields flag them as 'no charge' (CS='NC'), cosmetic (CT like COS/S9999MN), or specific vision codes (V2786F/V2787F/V27878F), it returns the billed charge as-is (or zero when the billed charge is itself zero) instead of running normal fee-schedule pricing.
  2. 101.6% of the APC-Rates fee schedule ⚠︎ named “100% of HP APC Rates + 1.6% MN Care Tax” but configured at 101.6%
Adjustments — all apply, in order
  1. modifier 1 present → 0% of the running amount
  2. modifier Y present → 0% of the running amount
  3. zero out charges excluded by the Bundled-Procedures schedule
  4. modifier 25 present → 80% of the running amount
  5. modifier 50 present → 150% of the running amount
  6. modifier 52 present → 50% of the running amount
  7. modifier 54 present → 70% of the running amount
  8. cap each charge and the account total at 100% of billed charges
  9. Medicare multiple-surgery reduction — pays 100/50%
  10. multiple-surgery reduction (contract rules) — pays 100/0%
  11. custom SQL — Date-tiered flat fee for HCPCS V2785 (corneal donor tissue/processing) with a 1.8% markup: $3850 before 2017-04-01, $4050 to 2019-04-01, $4400 for 2023-01-01..2024-05-31, $5250 for 2024-06-01..2024-12-31, $5470 from 2025-01-01, else $4300.
HealthPartners-MSHO-ASC-20242 base · 12 adj
HealthPartners MSHO
Facility · Minnesota Eye Consultants, Minnesota Eye Laser And Surgery Centers, Hospital/ASC · 2024-01-01 → 2025-05-31
Base terms — first match wins
  1. custom SQL — A cosmetic/no-charge carve-out override: for charges whose extracted code fields flag them as 'no charge' (CS='NC'), cosmetic (CT like COS/S9999MN), or specific vision codes (V2786F/V2787F/V27878F), it returns the billed charge as-is (or zero when the billed charge is itself zero) instead of running normal fee-schedule pricing.
  2. 101.8% of the APC-Rates fee schedule ⚠︎ named “100% of HP APC Rates + 1.8% MN Care Tax” but configured at 101.8%
Adjustments — all apply, in order
  1. modifier 1 present → 0% of the running amount
  2. modifier Y present → 0% of the running amount
  3. zero out charges excluded by the Bundled-Procedures schedule
  4. modifier 25 present → 80% of the running amount
  5. modifier 50 present → 150% of the running amount
  6. modifier 52 present → 50% of the running amount
  7. modifier 54 present → 70% of the running amount
  8. cap each charge and the account total at 100% of billed charges
  9. Medicare multiple-surgery reduction — pays 100/50%
  10. multiple-surgery reduction (contract rules) — pays 100/0%
  11. custom SQL — Date-tiered flat fee for HCPCS V2785 (corneal donor tissue/processing) with a 1.8% markup: $3850 before 2017-04-01, $4050 to 2019-04-01, $4400 for 2023-01-01..2024-05-31, $5250 for 2024-06-01..2024-12-31, $5470 from 2025-01-01, else $4300.
  12. custom SQL — Hardcoded price override for drug HCPCS J1097, effective 6/1/2025: pays a fixed $153.50 x 1.018 inflation-style multiplier, but only for service dates on/after 6/1/2025.
HealthPartners-MSHO-ASC-20253 base · 13 adj
HealthPartners MSHO
Facility · Minnesota Eye Consultants, Minnesota Eye Laser And Surgery Centers, Hospital/ASC · 2025-06-01 → 2099-12-31
Base terms — first match wins
  1. custom SQL — A cosmetic/no-charge carve-out override: for charges whose extracted code fields flag them as 'no charge' (CS='NC'), cosmetic (CT like COS/S9999MN), or specific vision codes (V2786F/V2787F/V27878F), it returns the billed charge as-is (or zero when the billed charge is itself zero) instead of running normal fee-schedule pricing.
  2. 101.8% of the Carve-Outs fee schedule
  3. 101.8% of the APC-Rates fee schedule ⚠︎ named “100% of HP APC Rates + 1.8% MN Care Tax” but configured at 101.8%
Adjustments — all apply, in order
  1. modifier 1 present → 0% of the running amount
  2. modifier Y present → 0% of the running amount
  3. zero out charges excluded by the Bundled-Procedures schedule
  4. zero out charges excluded by the Bundled-Codes schedule
  5. modifier 25 present → 80% of the running amount
  6. modifier 50 present → 150% of the running amount
  7. modifier 52 present → 50% of the running amount
  8. modifier 54 present → 70% of the running amount
  9. cap each charge and the account total at 100% of billed charges
  10. Medicare multiple-surgery reduction — pays 100/50%
  11. multiple-surgery reduction (contract rules) — pays 100/0%
  12. custom SQL — Date-tiered flat fee for HCPCS V2785 (corneal donor tissue/processing) with a 1.8% markup: $3850 before 2017-04-01, $4050 to 2019-04-01, $4400 for 2023-01-01..2024-05-31, $5250 for 2024-06-01..2024-12-31, $5470 from 2025-01-01, else $4300.
  13. custom SQL — Hardcoded price override for drug HCPCS J1097, effective 6/1/2025: pays a fixed $153.50 x 1.018 inflation-style multiplier, but only for service dates on/after 6/1/2025.
HealthPartners-Medicare3 base · 9 adj
HealthPartners Medicare
Profee · Minnesota Eye Consultants, Minnesota Eye Laser And Surgery Centers, Minnesota Retina Associates, Northwest Eye Clinic, Southwest Eye Care · 2016-01-01 → 2018-12-31
Base terms — first match wins
  1. custom SQL — A cosmetic/no-charge carve-out override: for charges whose extracted code fields flag them as 'no charge' (CS='NC'), cosmetic (CT like COS/S9999MN), or specific vision codes (V2786F/V2787F/V27878F), it returns the billed charge as-is (or zero when the billed charge is itself zero) instead of running normal fee-schedule pricing.
  2. custom SQL — Professional-fee ('Profee') schedule lookup that selects between 'Profee-Hospital' and 'Profee-Clinic' schedules based on the charge's place-of-service, returning the matching fee * Units.
  3. 70% of billed charges
Adjustments — all apply, in order
  1. modifier 1 present → 0% of the running amount
  2. modifier Y present → 0% of the running amount
  3. rescale by a percentage read from the Mid-Level-Charges schedule — when MidLevelProviders Mid-Level is present
  4. modifier 50 present → 200% of the running amount
  5. modifier 52 present → 50% of the running amount
  6. modifier 54 present → 70% of the running amount
  7. Medicare multiple-procedure reduction — base codes 2, 3; pays 100/50%
  8. modifier 50 present → 75% of the running amount
  9. cap each charge and the account total at 100% of billed charges
HealthPartners-Medicare-ASC2 base · 12 adj
HealthPartners Medicare
Facility · Hospital/ASC · 2016-01-01 → 2018-12-31
Base terms — first match wins
  1. custom SQL — A cosmetic/no-charge carve-out override: for charges whose extracted code fields flag them as 'no charge' (CS='NC'), cosmetic (CT like COS/S9999MN), or specific vision codes (V2786F/V2787F/V27878F), it returns the billed charge as-is (or zero when the billed charge is itself zero) instead of running normal fee-schedule pricing.
  2. 100% of the APC-Rates fee schedule
Adjustments — all apply, in order
  1. modifier 1 present → 0% of the running amount
  2. modifier Y present → 0% of the running amount
  3. zero out charges excluded by the Bundled-Procedures schedule
  4. modifier 25 present → 80% of the running amount
  5. modifier 50 present → 150% of the running amount
  6. modifier 52 present → 50% of the running amount
  7. modifier 54 present → 70% of the running amount
  8. cap each charge and the account total at 100% of billed charges
  9. Medicare multiple-surgery reduction — pays 100/50%
  10. multiple-surgery reduction (contract rules) — pays 100/0%
  11. custom SQL — Date-tiered flat fee for HCPCS V2785 (corneal donor tissue/processing) with a 1.8% markup: $3850 before 2017-04-01, $4050 to 2019-04-01, $4400 for 2023-01-01..2024-05-31, $5250 for 2024-06-01..2024-12-31, $5470 from 2025-01-01, else $4300.
  12. custom SQL — Hardcoded price override for drug HCPCS J1097, effective 6/1/2025: pays a fixed $153.50 x 1.018 inflation-style multiplier, but only for service dates on/after 6/1/2025.
HealthPartners-UVP-Profee3 base · 9 adj
Cigna, GreatWest/Cigna, Healthgram, HealthPartners
Profee · Southwest Eye Care · 2025-01-01 → 2099-12-31
Curative
Profee · Southwest Eye Care · 2026-01-01 → 2999-12-31
Base terms — first match wins
  1. custom SQL — A cosmetic/no-charge carve-out override: for charges whose extracted code fields flag them as 'no charge' (CS='NC'), cosmetic (CT like COS/S9999MN), or specific vision codes (V2786F/V2787F/V27878F), it returns the billed charge as-is (or zero when the billed charge is itself zero) instead of running normal fee-schedule pricing.
  2. 101.8% of the UVP-Profee-Clinic fee schedule — when PlaceOfService 11 is present
  3. 101.8% of the UVP-Profee-Hospital fee schedule — when PlaceOfService 11 is absent
Adjustments — all apply, in order
  1. modifier 1 present → 0% of the running amount
  2. modifier Y present → 0% of the running amount
  3. rescale by a percentage read from the Mid-Level-Charges schedule — when MidLevelProviders Mid-Level is present
  4. modifier 50 present → 150% of the running amount
  5. modifier 52 present → 50% of the running amount
  6. modifier 54 present → 70% of the running amount
  7. modifier 78 present → 84% of the running amount
  8. Medicare multiple-procedure reduction — base codes 2, 3; pays 100/50%
  9. cap each charge and the account total at 100% of billed charges
MN-Medical-Assistance1 base · 0 adj
MN Medical Assistance
Facility · Hospital/ASC · 2000-01-01 → 2099-12-31
MN Medical Assistance
Profee · all facilities · 2000-01-01 → 2099-12-31
Base terms — first match wins
  1. flat $0
Medica4 base · 10 adj
Medica, Medica IFB
Profee · all facilities · 2016-01-01 → 2020-04-30
Base terms — first match wins
  1. custom SQL — A cosmetic/no-charge carve-out override: for charges whose extracted code fields flag them as 'no charge' (CS='NC'), cosmetic (CT like COS/S9999MN), or specific vision codes (V2786F/V2787F/V27878F), it returns the billed charge as-is (or zero when the billed charge is itself zero) instead of running normal fee-schedule pricing.
  2. custom SQL — A flat 60% of billed charges override for two specific procedure codes (0402T and a custom '66999PTK' code).
  3. 100% of the Medica-Exceptions fee schedule
  4. custom SQL — Same Profee fee-schedule lookup as idx32/36/44, but with no dedup/tie-break at all across matching schedule rows.
Adjustments — all apply, in order
  1. modifier 1 present → 0% of the running amount
  2. modifier Y present → 0% of the running amount
  3. mid-level provider reduction (by NUCC taxonomy)
  4. modifier 50 present → 200% of the running amount
  5. modifier 52 present → 50% of the running amount
  6. modifier 54 present → 80% of the running amount
  7. modifier 78 present → 84% of the running amount
  8. Medicare multiple-procedure reduction — base codes 2, 3; pays 100/50%
  9. modifier 50 present → 75% of the running amount
  10. cap each charge and the account total at 100% of billed charges
Medica Advantage Sol Senior Plan9 base · 17 adj
Medica Advantage Sol Senior Plan
Profee · all facilities · 2019-01-01 → 2099-12-31
Base terms — first match wins
  1. 0% of the Non-Covered-Services fee schedule
  2. custom SQL — A cosmetic/no-charge carve-out override: for charges whose extracted code fields flag them as 'no charge' (CS='NC'), cosmetic (CT like COS/S9999MN), or specific vision codes (V2786F/V2787F/V27878F), it returns the billed charge as-is (or zero when the billed charge is itself zero) instead of running normal fee-schedule pricing.
  3. 100% of the Medicare-Contractor-Codes fee schedule
  4. 100% of Medicare drug
  5. 100% of Medicare lab
  6. 100% of Medicare DME
  7. 100% of Medicare RVU
  8. 100% of the Medicare-MPFSP fee schedule
  9. flat $0
Adjustments — all apply, in order
  1. custom SQL — Flat $19.41 fee for CPT 92015 (refraction), restricted to a fixed 5/1/2020-3/31/2022 date window; returns no row outside that window.
  2. modifier 1 present → 0% of the running amount
  3. modifier Y present → 0% of the running amount
  4. Medicare multiple-endoscopy reduction
  5. Medicare multiple-procedure reduction — base codes 2, 3; pays 100/50%
  6. mid-level provider reduction (by NUCC taxonomy)
  7. modifier 22 present → 135% of the running amount
  8. modifier 50 present → 150% of the running amount
  9. modifier 52 present → 50% of the running amount
  10. modifier 54 present → 80% of the running amount
  11. modifier 62 present → 62.5% of the running amount
  12. modifier 78 present → 70% of the running amount
  13. modifier 80 present → 16% of the running amount
  14. modifier 81 present → 16% of the running amount
  15. modifier 82 present → 16% of the running amount
  16. modifier AS present → 13.6% of the running amount
  17. cap each charge and the account total at 100% of billed charges
Medica Advantage Sol Senior Plan-ASC5 base · 8 adj
Medica Advantage Sol Senior Plan
Facility · Hospital/ASC · 2019-01-01 → 2021-12-31
Base terms — first match wins
  1. 0% of the Non-Covered-Services fee schedule
  2. custom SQL — A cosmetic/no-charge carve-out override: for charges whose extracted code fields flag them as 'no charge' (CS='NC'), cosmetic (CT like COS/S9999MN), or specific vision codes (V2786F/V2787F/V27878F), it returns the billed charge as-is (or zero when the billed charge is itself zero) instead of running normal fee-schedule pricing.
  3. 100% of billed charges — when ProcCodeFilter V2785 is present
  4. 100% of Medicare ASC
  5. flat $0
Adjustments — all apply, in order
  1. custom SQL — Duplicate of idx31/idx47: pays compounded ophthalmic drug J1097 at full billed charges for dates of service on/after 1/1/2019, for a different customer or FeeLogic.
  2. modifier 1 present → 0% of the running amount
  3. modifier Y present → 0% of the running amount
  4. multiple-endoscopy reduction (contract rules)
  5. modifier 50 present → 150% of the running amount
  6. modifier 52 present → 50% of the running amount
  7. cap each charge and the account total at 100% of billed charges
  8. multiple-surgery reduction (contract rules) — pays 100/50%
Medica Advantage Sol Senior Plan-ASC-20226 base · 8 adj
Medica Advantage Sol Senior Plan
Facility · Hospital/ASC · 2022-01-01 → 2099-12-31
Base terms — first match wins
  1. 0% of the Non-Covered-Services fee schedule
  2. custom SQL — A cosmetic/no-charge carve-out override: for charges whose extracted code fields flag them as 'no charge' (CS='NC'), cosmetic (CT like COS/S9999MN), or specific vision codes (V2786F/V2787F/V27878F), it returns the billed charge as-is (or zero when the billed charge is itself zero) instead of running normal fee-schedule pricing.
  3. 100% of billed charges — when ProcCodeFilter V2785 is present
  4. 100% of Medicare ASC
  5. 100% of the Carve-Outs fee schedule
  6. flat $0
Adjustments — all apply, in order
  1. custom SQL — Duplicate of idx31/idx47: pays compounded ophthalmic drug J1097 at full billed charges for dates of service on/after 1/1/2019, for a different customer or FeeLogic.
  2. modifier 1 present → 0% of the running amount
  3. modifier Y present → 0% of the running amount
  4. multiple-endoscopy reduction (contract rules)
  5. modifier 50 present → 150% of the running amount
  6. modifier 52 present → 50% of the running amount
  7. cap each charge and the account total at 100% of billed charges
  8. multiple-surgery reduction (contract rules) — pays 100/50%
Medica-20203 base · 9 adj
Medica, Medica IFB
Profee · Minnesota Eye Consultants, Minnesota Eye Laser And Surgery Centers · 2020-05-01 → 2099-12-31
Base terms — first match wins
  1. custom SQL — A cosmetic/no-charge carve-out override: for charges whose extracted code fields flag them as 'no charge' (CS='NC'), cosmetic (CT like COS/S9999MN), or specific vision codes (V2786F/V2787F/V27878F), it returns the billed charge as-is (or zero when the billed charge is itself zero) instead of running normal fee-schedule pricing.
  2. custom SQL — Prices two device/investigational codes (0402T and a local pseudo-code 66999PTK) at 60% of billed charges, except 66999PTK gets a flat $2,190 override for dates on/after 2024-01-01 per a later ticket, while 0402T stays at 60% of charges regardless of date.
  3. custom SQL — Same Profee fee-schedule lookup as idx32/36/44, but with no dedup/tie-break at all across matching schedule rows.
Adjustments — all apply, in order
  1. modifier 1 present → 0% of the running amount
  2. modifier Y present → 0% of the running amount
  3. mid-level provider reduction (by NUCC taxonomy)
  4. modifier 50 present → 150% of the running amount
  5. modifier 52 present → 50% of the running amount
  6. modifier 54 present → 80% of the running amount
  7. modifier 78 present → 84% of the running amount
  8. Medicare multiple-procedure reduction — base codes 2, 3; pays 100/50%
  9. cap each charge and the account total at 100% of billed charges
Medica-ASC4 base · 6 adj
Medica, Medica IFB
Facility · Hospital/ASC · 2016-01-01 → 2021-12-31
Base terms — first match wins
  1. custom SQL — A cosmetic/no-charge carve-out override: for charges whose extracted code fields flag them as 'no charge' (CS='NC'), cosmetic (CT like COS/S9999MN), or specific vision codes (V2786F/V2787F/V27878F), it returns the billed charge as-is (or zero when the billed charge is itself zero) instead of running normal fee-schedule pricing.
  2. custom SQL — Duplicate of the audiology full-charge-pass-through rule (hash 89a730a065261378): pays 100% of billed charges for the same hearing-aid/audiology code list on/after 2019-01-01.
  3. 100% of the Unlisted-Code-Rates fee schedule
  4. 100% of the APC-Rates fee schedule
Adjustments — all apply, in order
  1. modifier 1 present → 0% of the running amount
  2. modifier Y present → 0% of the running amount
  3. modifier 50 present → 150% of the running amount
  4. modifier 52 present → 50% of the running amount
  5. cap each charge and the account total at 100% of billed charges
  6. multiple-surgery reduction (contract rules) — pays 100/50%
Medica-ASC-20225 base · 6 adj
Medica, Medica IFB
Facility · Hospital/ASC · 2022-01-01 → 2099-12-31
Base terms — first match wins
  1. custom SQL — A cosmetic/no-charge carve-out override: for charges whose extracted code fields flag them as 'no charge' (CS='NC'), cosmetic (CT like COS/S9999MN), or specific vision codes (V2786F/V2787F/V27878F), it returns the billed charge as-is (or zero when the billed charge is itself zero) instead of running normal fee-schedule pricing.
  2. 100% of the Carve-Outs fee schedule
  3. custom SQL — Duplicate of the audiology full-charge-pass-through rule (hash 89a730a065261378): pays 100% of billed charges for the same hearing-aid/audiology code list on/after 2019-01-01.
  4. 100% of the Unlisted-Code-Rates fee schedule
  5. 100% of the APC-Rates fee schedule
Adjustments — all apply, in order
  1. modifier 1 present → 0% of the running amount
  2. modifier Y present → 0% of the running amount
  3. modifier 50 present → 150% of the running amount
  4. modifier 52 present → 50% of the running amount
  5. cap each charge and the account total at 100% of billed charges
  6. multiple-surgery reduction (contract rules) — pays 100/50%
Medica-Dual2 base · 9 adj
Medica Dual
Profee · all facilities · 2016-01-01 → 2017-12-31
Base terms — first match wins
  1. custom SQL — A cosmetic/no-charge carve-out override: for charges whose extracted code fields flag them as 'no charge' (CS='NC'), cosmetic (CT like COS/S9999MN), or specific vision codes (V2786F/V2787F/V27878F), it returns the billed charge as-is (or zero when the billed charge is itself zero) instead of running normal fee-schedule pricing.
  2. custom SQL — Same facility/non-facility profee schedule lookup as its sibling snippet (1eb2f3dca1ef348e), but discounted 2% instead of marked up 3%.
Adjustments — all apply, in order
  1. modifier 1 present → 0% of the running amount
  2. modifier Y present → 0% of the running amount
  3. mid-level provider reduction (by NUCC taxonomy)
  4. modifier 50 present → 150% of the running amount
  5. modifier 52 present → 50% of the running amount
  6. modifier 54 present → 80% of the running amount
  7. modifier 78 present → 84% of the running amount
  8. Medicare multiple-procedure reduction — base codes 2, 3; pays 100/50%
  9. cap each charge and the account total at 100% of billed charges
Medica-Dual-20189 base · 16 adj
Medica Dual
Profee · Minnesota Eye Consultants, Minnesota Eye Laser And Surgery Centers, Minnesota Retina Associates, Northwest Eye Clinic, Southwest Eye Care · 2018-01-01 → 2099-12-31
Base terms — first match wins
  1. 0% of the Non-Covered-Services fee schedule
  2. custom SQL — A cosmetic/no-charge carve-out override: for charges whose extracted code fields flag them as 'no charge' (CS='NC'), cosmetic (CT like COS/S9999MN), or specific vision codes (V2786F/V2787F/V27878F), it returns the billed charge as-is (or zero when the billed charge is itself zero) instead of running normal fee-schedule pricing.
  3. 100% of the Medicare-Contractor-Codes fee schedule
  4. 100% of Medicare drug
  5. 100% of Medicare lab
  6. 100% of Medicare DME
  7. 100% of Medicare RVU
  8. 100% of Medicare ASC
  9. flat $0
Adjustments — all apply, in order
  1. modifier 1 present → 0% of the running amount
  2. modifier Y present → 0% of the running amount
  3. Medicare multiple-endoscopy reduction
  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 50 present → 150% of the running amount
  8. modifier 52 present → 50% of the running amount
  9. modifier 54 present → 80% of the running amount
  10. modifier 62 present → 62.5% of the running amount
  11. modifier 78 present → 70% of the running amount
  12. modifier 80 present → 16% of the running amount
  13. modifier 81 present → 16% of the running amount
  14. modifier 82 present → 16% of the running amount
  15. modifier AS present → 13.6% of the running amount
  16. cap each charge and the account total at 100% of billed charges
Medica-Dual-ASC4 base · 6 adj
Medica Dual
Facility · Hospital/ASC · 2020-01-15 → 2021-12-31
Medica Dual
Facility · Hospital/ASC · 2016-01-01 → 2017-12-31
Base terms — first match wins
  1. custom SQL — A cosmetic/no-charge carve-out override: for charges whose extracted code fields flag them as 'no charge' (CS='NC'), cosmetic (CT like COS/S9999MN), or specific vision codes (V2786F/V2787F/V27878F), it returns the billed charge as-is (or zero when the billed charge is itself zero) instead of running normal fee-schedule pricing.
  2. custom SQL — Pays 100% of billed charges (pass-through) for a fixed list of ocular-prosthetic/audiology/drug codes (V2785, V2790, J1097, C1839, L8610, L8612) for service dates on/after 2020-01-01.
  3. 100% of the Unlisted-Code-Rates fee schedule
  4. 100% of the APC-Rates fee schedule
Adjustments — all apply, in order
  1. modifier 1 present → 0% of the running amount
  2. modifier Y present → 0% of the running amount
  3. modifier 50 present → 150% of the running amount
  4. modifier 52 present → 50% of the running amount
  5. Medicare multiple-surgery reduction — pays 100/50%
  6. cap each charge and the account total at 100% of billed charges
Medica-Dual-ASC-20185 base · 8 adj
Medica Dual
Facility · Hospital/ASC · 2018-01-01 → 2020-01-14
Base terms — first match wins
  1. 0% of the Non-Covered-Services fee schedule
  2. custom SQL — A cosmetic/no-charge carve-out override: for charges whose extracted code fields flag them as 'no charge' (CS='NC'), cosmetic (CT like COS/S9999MN), or specific vision codes (V2786F/V2787F/V27878F), it returns the billed charge as-is (or zero when the billed charge is itself zero) instead of running normal fee-schedule pricing.
  3. 100% of billed charges — when ProcCodeFilter V2785 is present
  4. 100% of Medicare ASC
  5. flat $0
Adjustments — all apply, in order
  1. custom SQL — Duplicate of idx31/idx45: pays compounded ophthalmic drug J1097 at full billed charges for dates of service on/after 1/1/2019.
  2. modifier 1 present → 0% of the running amount
  3. modifier Y present → 0% of the running amount
  4. Medicare multiple-endoscopy reduction
  5. modifier 50 present → 150% of the running amount
  6. modifier 52 present → 50% of the running amount
  7. Medicare multiple-surgery reduction — pays 100/50%
  8. cap each charge and the account total at 100% of billed charges
Medica-Dual-ASC-202210 base · 6 adj
Medica Dual
Facility · Hospital/ASC · 2022-01-01 → 2099-12-31
Base terms — first match wins
  1. custom SQL — A cosmetic/no-charge carve-out override: for charges whose extracted code fields flag them as 'no charge' (CS='NC'), cosmetic (CT like COS/S9999MN), or specific vision codes (V2786F/V2787F/V27878F), it returns the billed charge as-is (or zero when the billed charge is itself zero) instead of running normal fee-schedule pricing.
  2. 100% of the Carve-Outs fee schedule
  3. 100% of billed charges — when ProcCodeFilter V2785 is present
  4. 100% of billed charges — when ProcCodeFilter V2790 is present
  5. 100% of billed charges — when ProcCodeFilter J1097 is present
  6. 100% of billed charges — when ProcCodeFilter C1839 is present
  7. 100% of billed charges — when ProcCodeFilter L8610 is present
  8. 100% of billed charges — when ProcCodeFilter L8612 is present
  9. 100% of the Unlisted-Code-Rates fee schedule
  10. 100% of the APC-Rates fee schedule
Adjustments — all apply, in order
  1. modifier 1 present → 0% of the running amount
  2. modifier Y present → 0% of the running amount
  3. modifier 50 present → 150% of the running amount
  4. modifier 52 present → 50% of the running amount
  5. Medicare multiple-surgery reduction — pays 100/50%
  6. cap each charge and the account total at 100% of billed charges
Medica-MA3 base · 9 adj
Medica MA
Profee · Minnesota Eye Consultants, Minnesota Eye Laser And Surgery Centers, Minnesota Retina Associates, Northwest Eye Clinic, Southwest Eye Care · 2016-01-01 → 2099-12-31
Base terms — first match wins
  1. custom SQL — A cosmetic/no-charge carve-out override: for charges whose extracted code fields flag them as 'no charge' (CS='NC'), cosmetic (CT like COS/S9999MN), or specific vision codes (V2786F/V2787F/V27878F), it returns the billed charge as-is (or zero when the billed charge is itself zero) instead of running normal fee-schedule pricing.
  2. 100% of the Medica-Exceptions fee schedule
  3. custom SQL — Same Profee fee-schedule lookup as idx32/36/44, but with no dedup/tie-break at all across matching schedule rows.
Adjustments — all apply, in order
  1. modifier 1 present → 0% of the running amount
  2. modifier Y present → 0% of the running amount
  3. mid-level provider reduction (by NUCC taxonomy)
  4. modifier 50 present → 150% of the running amount
  5. modifier 52 present → 50% of the running amount
  6. modifier 54 present → 80% of the running amount
  7. modifier 78 present → 84% of the running amount
  8. Medicare multiple-procedure reduction — base codes 2, 3; pays 100/50%
  9. cap each charge and the account total at 100% of billed charges
Medica-MA-ASC4 base · 6 adj
Medica MA
Facility · Hospital/ASC · 2016-01-01 → 2025-12-31
Base terms — first match wins
  1. custom SQL — A cosmetic/no-charge carve-out override: for charges whose extracted code fields flag them as 'no charge' (CS='NC'), cosmetic (CT like COS/S9999MN), or specific vision codes (V2786F/V2787F/V27878F), it returns the billed charge as-is (or zero when the billed charge is itself zero) instead of running normal fee-schedule pricing.
  2. custom SQL — Pays 100% of billed charges (full pass-through) for a fixed list of hearing-aid/audiology-adjacent codes (V2785, V2790, J1097, C1839, L8610, L8612) for dates of service on/after 2019-01-01.
  3. 100% of the Unlisted-Code-Rates fee schedule
  4. 100% of the APC-Rates fee schedule
Adjustments — all apply, in order
  1. modifier 1 present → 0% of the running amount
  2. modifier Y present → 0% of the running amount
  3. modifier 50 present → 150% of the running amount
  4. modifier 52 present → 50% of the running amount
  5. Medicare multiple-surgery reduction — pays 100/50%
  6. cap each charge and the account total at 100% of billed charges
Medica-MA-ASC5 base · 6 adj
Medica MA
Facility · Hospital/ASC · 2026-01-01 → 2099-12-31
Base terms — first match wins
  1. custom SQL — A cosmetic/no-charge carve-out override: for charges whose extracted code fields flag them as 'no charge' (CS='NC'), cosmetic (CT like COS/S9999MN), or specific vision codes (V2786F/V2787F/V27878F), it returns the billed charge as-is (or zero when the billed charge is itself zero) instead of running normal fee-schedule pricing.
  2. custom SQL — Pays 100% of billed charges (full pass-through) for a fixed list of hearing-aid/audiology-adjacent codes (V2785, V2790, J1097, C1839, L8610, L8612) for dates of service on/after 2019-01-01.
  3. 100% of the Unlisted-Code-Rates fee schedule
  4. 100% of the Carve-Outs fee schedule
  5. 100% of the APC-Rates fee schedule
Adjustments — all apply, in order
  1. modifier 1 present → 0% of the running amount
  2. modifier Y present → 0% of the running amount
  3. modifier 50 present → 150% of the running amount
  4. modifier 52 present → 50% of the running amount
  5. Medicare multiple-surgery reduction — pays 100/50%
  6. cap each charge and the account total at 100% of billed charges
Medica-Medicare2 base · 9 adj
Medica Medicare
Profee · Minnesota Eye Consultants, Minnesota Eye Laser And Surgery Centers, Minnesota Retina Associates, Northwest Eye Clinic, Southwest Eye Care · 2016-01-01 → 2018-12-31
Base terms — first match wins
  1. custom SQL — A cosmetic/no-charge carve-out override: for charges whose extracted code fields flag them as 'no charge' (CS='NC'), cosmetic (CT like COS/S9999MN), or specific vision codes (V2786F/V2787F/V27878F), it returns the billed charge as-is (or zero when the billed charge is itself zero) instead of running normal fee-schedule pricing.
  2. custom SQL — Professional-fee ('Profee') schedule lookup that selects between 'Profee-Hospital' and 'Profee-Clinic' schedules based on the charge's place-of-service, returning the matching fee * Units.
Adjustments — all apply, in order
  1. modifier 1 present → 0% of the running amount
  2. modifier Y present → 0% of the running amount
  3. mid-level provider reduction (by NUCC taxonomy)
  4. modifier 50 present → 150% of the running amount
  5. modifier 52 present → 50% of the running amount
  6. modifier 54 present → 80% of the running amount
  7. modifier 78 present → 84% of the running amount
  8. Medicare multiple-procedure reduction — base codes 2, 3; pays 100/50%
  9. cap each charge and the account total at 100% of billed charges
Medica-Medicare-ASC3 base · 7 adj
Medica Medicare
Facility · Hospital/ASC · 2016-01-01 → 2018-12-31
Base terms — first match wins
  1. custom SQL — A cosmetic/no-charge carve-out override: for charges whose extracted code fields flag them as 'no charge' (CS='NC'), cosmetic (CT like COS/S9999MN), or specific vision codes (V2786F/V2787F/V27878F), it returns the billed charge as-is (or zero when the billed charge is itself zero) instead of running normal fee-schedule pricing.
  2. 100% of the Unlisted-Code-Rates fee schedule
  3. 100% of the APC-Rates fee schedule
Adjustments — all apply, in order
  1. modifier 1 present → 0% of the running amount
  2. modifier Y present → 0% of the running amount
  3. modifier 50 present → 150% of the running amount
  4. modifier 52 present → 50% of the running amount
  5. Medicare multiple-surgery reduction — pays 100/50%
  6. custom SQL — For four specific ocular-prosthetic/contact-lens HCPCS codes (L8610, L8612, V2785, V2790), sets allowed to 96.04% of billed charge (0.98 squared).
  7. cap each charge and the account total at 100% of billed charges
Medica-Senior-Plan-ASC9 base · 6 adj
Medica Senior Plan
Facility · Hospital/ASC · 2022-01-01 → 2099-12-31
Base terms — first match wins
  1. custom SQL — A cosmetic/no-charge carve-out override: for charges whose extracted code fields flag them as 'no charge' (CS='NC'), cosmetic (CT like COS/S9999MN), or specific vision codes (V2786F/V2787F/V27878F), it returns the billed charge as-is (or zero when the billed charge is itself zero) instead of running normal fee-schedule pricing.
  2. 100% of the Carve-Outs fee schedule
  3. 100% of billed charges — when ProcCodeFilter V2785 is present
  4. 100% of billed charges — when ProcCodeFilter V2790 is present
  5. 100% of billed charges — when ProcCodeFilter J1097 is present
  6. 100% of billed charges — when ProcCodeFilter C1839 is present
  7. 100% of billed charges — when ProcCodeFilter L8610 is present
  8. 100% of billed charges — when ProcCodeFilter L8612 is present
  9. 100% of the APC-Rates fee schedule
Adjustments — all apply, in order
  1. modifier 1 present → 0% of the running amount
  2. modifier Y present → 0% of the running amount
  3. modifier 50 present → 150% of the running amount
  4. modifier 52 present → 50% of the running amount
  5. Medicare multiple-surgery reduction — pays 100/50%
  6. cap each charge and the account total at 100% of billed charges
Medica-UVP3 base · 9 adj
Medica, Medica IFB
Profee · Minnesota Retina Associates, Northwest Eye Clinic · 2024-04-01 → 2099-12-31
Medica, Medica IFB
Profee · Southwest Eye Care, Clinic · 2024-04-01 → 2099-12-31
Base terms — first match wins
  1. custom SQL — A cosmetic/no-charge carve-out override: for charges whose extracted code fields flag them as 'no charge' (CS='NC'), cosmetic (CT like COS/S9999MN), or specific vision codes (V2786F/V2787F/V27878F), it returns the billed charge as-is (or zero when the billed charge is itself zero) instead of running normal fee-schedule pricing.
  2. 100% of the UVP-Profee-Clinic fee schedule
  3. 60% of billed charges
Adjustments — all apply, in order
  1. modifier 1 present → 0% of the running amount
  2. modifier Y present → 0% of the running amount
  3. mid-level provider reduction (by NUCC taxonomy)
  4. modifier 50 present → 150% of the running amount
  5. modifier 52 present → 50% of the running amount
  6. modifier 54 present → 80% of the running amount
  7. modifier 78 present → 84% of the running amount
  8. Medicare multiple-procedure reduction — base codes 2, 3; pays 100/50%
  9. cap each charge and the account total at 100% of billed charges
Medica-UVP -Hosp3 base · 9 adj
Medica, Medica IFB
Profee · Southwest Eye Care, Hospital/ASC · 2024-04-01 → 2099-12-31
Base terms — first match wins
  1. custom SQL — A cosmetic/no-charge carve-out override: for charges whose extracted code fields flag them as 'no charge' (CS='NC'), cosmetic (CT like COS/S9999MN), or specific vision codes (V2786F/V2787F/V27878F), it returns the billed charge as-is (or zero when the billed charge is itself zero) instead of running normal fee-schedule pricing.
  2. 100% of the UVP-Profee-Hospital fee schedule
  3. 60% of billed charges
Adjustments — all apply, in order
  1. modifier 1 present → 0% of the running amount
  2. modifier Y present → 0% of the running amount
  3. mid-level provider reduction (by NUCC taxonomy)
  4. modifier 50 present → 150% of the running amount
  5. modifier 52 present → 50% of the running amount
  6. modifier 54 present → 80% of the running amount
  7. modifier 78 present → 84% of the running amount
  8. Medicare multiple-procedure reduction — base codes 2, 3; pays 100/50%
  9. cap each charge and the account total at 100% of billed charges
Medicare10 base · 16 adj
Medicare, Other Commercial Medicare
Profee · all facilities · 2016-01-01 → 2099-12-31
AARP Senior Plan
Profee · Minnesota Eye Consultants, Minnesota Eye Laser And Surgery Centers, Minnesota Retina Associates, Northwest Eye Clinic, Southwest Eye Care · 2018-01-01 → 2099-12-31
Blue Cross MSHO, ChampVA, Humana Medicare, Tricare, UCare MSHO, United Healthcare Medicare
Profee · Minnesota Eye Consultants, Minnesota Eye Laser And Surgery Centers, Minnesota Retina Associates, Northwest Eye Clinic, Southwest Eye Care · 2016-01-01 → 2099-12-31
HealthPartners Medicare, Medica Medicare
Profee · Minnesota Eye Consultants, Minnesota Eye Laser And Surgery Centers, Minnesota Retina Associates, Northwest Eye Clinic, Southwest Eye Care · 2019-01-01 → 2099-12-31
Proposed Medicare
Profee · Minnesota Eye Consultants, Minnesota Eye Laser And Surgery Centers, Minnesota Retina Associates, Northwest Eye Clinic, Southwest Eye Care · 2023-01-01 → 2099-12-31
Medica Senior Plan
Profee · Minnesota Eye Consultants, Minnesota Eye Laser And Surgery Centers, Minnesota Retina Associates, Northwest Eye Clinic, Southwest Eye Care · 2019-01-01 → 2099-12-31
Humana
Profee · Minnesota Eye Consultants, Minnesota Eye Laser And Surgery Centers, Minnesota Retina Associates, Northwest Eye Clinic, Southwest Eye Care · 2016-01-01 → 2099-12-31
HealthPartners MSHO
Profee · Minnesota Retina Associates, Northwest Eye Clinic, Southwest Eye Care · 2024-01-01 → 2999-12-31
Cigna Medicare
Profee · Minnesota Eye Consultants, Minnesota Eye Laser And Surgery Centers, Minnesota Retina Associates, Northwest Eye Clinic, Southwest Eye Care · 2023-01-01 → 2099-12-31
Base terms — first match wins
  1. 0% of the Non-Covered-Services fee schedule
  2. custom SQL — A cosmetic/no-charge carve-out override: for charges whose extracted code fields flag them as 'no charge' (CS='NC'), cosmetic (CT like COS/S9999MN), or specific vision codes (V2786F/V2787F/V27878F), it returns the billed charge as-is (or zero when the billed charge is itself zero) instead of running normal fee-schedule pricing.
  3. 100% of the Medicare-Contractor-Codes fee schedule
  4. 100% of the Medicare-Exceptions fee schedule
  5. 100% of Medicare drug
  6. 100% of Medicare lab
  7. 100% of Medicare DME
  8. 100% of Medicare RVU
  9. 100% of the Medicare-MPFSP fee schedule
  10. flat $0
Adjustments — all apply, in order
  1. modifier 1 present → 0% of the running amount
  2. modifier Y present → 0% of the running amount
  3. Medicare multiple-endoscopy reduction
  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 50 present → 150% of the running amount
  8. modifier 52 present → 50% of the running amount
  9. modifier 54 present → 80% of the running amount
  10. modifier 62 present → 62.5% of the running amount
  11. modifier 78 present → 70% of the running amount
  12. modifier 80 present → 16% of the running amount
  13. modifier 81 present → 16% of the running amount
  14. modifier 82 present → 16% of the running amount
  15. modifier AS present → 13.6% of the running amount
  16. cap each charge and the account total at 100% of billed charges
Medicare-ASC6 base · 7 adj
Medicare, Other Commercial Medicare
Facility · Hospital/ASC · 2016-01-01 → 2099-12-31
AARP Senior Plan
Facility · Minnesota Eye Consultants, Minnesota Eye Laser And Surgery Centers, Minnesota Retina Associates, Northwest Eye Clinic, Southwest Eye Care, Hospital/ASC · 2018-01-01 → 2099-12-31
Blue Cross MSHO, ChampVA, Humana Medicare, Tricare, UCare Choices MN Sure, UCare MSHO, UCare Seniors, United Healthcare Medicare
Facility · Minnesota Eye Consultants, Minnesota Eye Laser And Surgery Centers, Minnesota Retina Associates, Northwest Eye Clinic, Southwest Eye Care, Hospital/ASC · 2016-01-01 → 2099-12-31
Cigna Medicare, HealthPartners Medicare, Medica Medicare
Facility · Minnesota Eye Consultants, Minnesota Eye Laser And Surgery Centers, Minnesota Retina Associates, Northwest Eye Clinic, Southwest Eye Care, Hospital/ASC · 2019-01-01 → 2099-12-31
Proposed Medicare
Facility · Minnesota Eye Consultants, Minnesota Eye Laser And Surgery Centers, Minnesota Retina Associates, Northwest Eye Clinic, Southwest Eye Care, Hospital/ASC · 2023-01-01 → 2099-12-31
HealthPartners MSHO
Facility · Minnesota Retina Associates, Northwest Eye Clinic, Southwest Eye Care · 2024-01-01 → 2999-12-31
Base terms — first match wins
  1. 0% of the Non-Covered-Services fee schedule
  2. custom SQL — A cosmetic/no-charge carve-out override: for charges whose extracted code fields flag them as 'no charge' (CS='NC'), cosmetic (CT like COS/S9999MN), or specific vision codes (V2786F/V2787F/V27878F), it returns the billed charge as-is (or zero when the billed charge is itself zero) instead of running normal fee-schedule pricing.
  3. 100% of billed charges — when ProcCodeFilter V2785 is present
  4. 100% of billed charges — when ProcCodeFilter J1097 is present
  5. 100% of Medicare ASC
  6. flat $0
Adjustments — all apply, in order
  1. modifier 1 present → 0% of the running amount
  2. modifier Y present → 0% of the running amount
  3. Medicare multiple-endoscopy reduction
  4. modifier 50 present → 150% of the running amount
  5. modifier 52 present → 50% of the running amount
  6. Medicare multiple-surgery reduction — pays 100/50%
  7. cap each charge and the account total at 100% of billed charges
PreferredOne6 base · 8 adj
PreferredOne
Profee · all facilities · 2017-01-01 → 2099-12-31
Base terms — first match wins
  1. custom SQL — A cosmetic/no-charge carve-out override: for charges whose extracted code fields flag them as 'no charge' (CS='NC'), cosmetic (CT like COS/S9999MN), or specific vision codes (V2786F/V2787F/V27878F), it returns the billed charge as-is (or zero when the billed charge is itself zero) instead of running normal fee-schedule pricing.
  2. custom SQL — Flat 55% of billed charges, restricted to three specific procedure codes (0191T, 0402T, 66999PTK).
  3. custom SQL — Optometry fee-schedule lookup that selects between a 'Optometry-Hospital' vs 'Optometry-Clinic' schedule based on the charge's place-of-service (via a secondary POS-Code-Indicators schedule), then returns the matching fee * Units. — when PrimaryCare Primary Care is present
  4. custom SQL — Optometry fee-schedule lookup that selects between a 'Optometry-Hospital' vs 'Optometry-Clinic' schedule based on the charge's place-of-service (via a secondary POS-Code-Indicators schedule), then returns the matching fee * Units. — when Optometrist Optometrist is present
  5. custom SQL — Looks up a per-unit fee from a facility/insurance/date-scoped 'Profee' fee schedule keyed by revenue/CPT code and modifier, adjusted for place-of-service (facility vs non-facility via a POS-code-indicator schedule), times units -- this is the canonical PercentOfFees pricing pattern reimplemented as raw admin SQL.
  6. custom SQL — Looks up a fee from the customer's own Fixed-Fees-Hospital/Fixed-Fees-Clinic schedule by charge-type code and modifier filter, picking the highest-priority matching record, with the facility-vs-clinic dimension resolved from an explicit POS code on the charge or, failing that, inferred from the facility name containing 'ASC'; multiplies by units.
Adjustments — all apply, in order
  1. modifier 1 present → 0% of the running amount
  2. modifier Y present → 0% of the running amount
  3. modifier 50 present → 150% of the running amount
  4. modifier 52 present → 50% of the running amount
  5. modifier 54 present → 80% of the running amount
  6. modifier 78 present → 70% of the running amount
  7. cap each charge and the account total at 100% of billed charges
  8. multiple-procedure reduction (contract rules) — base codes 2, 3; pays 100/50%
PreferredOne-20164 base · 8 adj
PreferredOne
Profee · all facilities · 2016-01-01 → 2016-12-31
Base terms — first match wins
  1. custom SQL — A cosmetic/no-charge carve-out override: for charges whose extracted code fields flag them as 'no charge' (CS='NC'), cosmetic (CT like COS/S9999MN), or specific vision codes (V2786F/V2787F/V27878F), it returns the billed charge as-is (or zero when the billed charge is itself zero) instead of running normal fee-schedule pricing.
  2. custom SQL — Optometry fee-schedule lookup that selects between a 'Optometry-Hospital' vs 'Optometry-Clinic' schedule based on the charge's place-of-service (via a secondary POS-Code-Indicators schedule), then returns the matching fee * Units. — when PrimaryCare Primary Care is present
  3. custom SQL — Optometry fee-schedule lookup that selects between a 'Optometry-Hospital' vs 'Optometry-Clinic' schedule based on the charge's place-of-service (via a secondary POS-Code-Indicators schedule), then returns the matching fee * Units. — when Optometrist Optometrist is present
  4. custom SQL — Looks up a per-unit fee from a facility/insurance/date-scoped 'Profee' fee schedule keyed by revenue/CPT code and modifier, adjusted for place-of-service (facility vs non-facility via a POS-code-indicator schedule), times units -- this is the canonical PercentOfFees pricing pattern reimplemented as raw admin SQL.
Adjustments — all apply, in order
  1. modifier 1 present → 0% of the running amount
  2. modifier Y present → 0% of the running amount
  3. modifier 50 present → 150% of the running amount
  4. modifier 52 present → 50% of the running amount
  5. modifier 54 present → 80% of the running amount
  6. modifier 78 present → 70% of the running amount
  7. cap each charge and the account total at 100% of billed charges
  8. multiple-procedure reduction (contract rules) — base codes 2, 3; pays 100/50%
PreferredOne-ASC4 base · 8 adj
PreferredOne
Facility · 5 named facilities · 2017-01-01 → 2020-12-31
Base terms — first match wins
  1. custom SQL — A cosmetic/no-charge carve-out override: for charges whose extracted code fields flag them as 'no charge' (CS='NC'), cosmetic (CT like COS/S9999MN), or specific vision codes (V2786F/V2787F/V27878F), it returns the billed charge as-is (or zero when the billed charge is itself zero) instead of running normal fee-schedule pricing.
  2. custom SQL — Pays three related ophthalmic codes (V2785, V2790 corneal tissue, J1097 compounded drug) at full billed charges for dates of service on/after 1/1/2018.
  3. 100% of the Payment-Exceptions fee schedule
  4. 100% of the APC-Rates fee schedule
Adjustments — all apply, in order
  1. modifier 1 present → 0% of the running amount
  2. modifier Y present → 0% of the running amount
  3. modifier 50 present → 150% of the running amount
  4. modifier 54 present → 80% of the running amount
  5. zero out charges excluded by the Bundled-Procedures schedule
  6. cap each charge and the account total at 100% of billed charges
  7. multiple-surgery reduction (contract rules) — pays 100/50%
  8. multiple-surgery reduction (contract rules) — pays 100/0%
PreferredOne-ASC-20162 base · 6 adj
PreferredOne
Facility · Hospital/ASC · 2016-01-01 → 2016-12-31
Base terms — first match wins
  1. custom SQL — A cosmetic/no-charge carve-out override: for charges whose extracted code fields flag them as 'no charge' (CS='NC'), cosmetic (CT like COS/S9999MN), or specific vision codes (V2786F/V2787F/V27878F), it returns the billed charge as-is (or zero when the billed charge is itself zero) instead of running normal fee-schedule pricing.
  2. 100% of the APC-Rates fee schedule
Adjustments — all apply, in order
  1. modifier 1 present → 0% of the running amount
  2. modifier Y present → 0% of the running amount
  3. modifier 50 present → 150% of the running amount
  4. cap each charge and the account total at 100% of billed charges
  5. multiple-surgery reduction (contract rules) — pays 100/50%
  6. custom SQL — Pays two corneal/ophthalmic codes (V2785, V2790) at full billed charges unconditionally, with no date restriction.
PreferredOne-ASC-20213 base · 8 adj
PreferredOne
Facility · Hospital/ASC · 2021-01-01 → 2021-12-31
Base terms — first match wins
  1. custom SQL — A cosmetic/no-charge carve-out override: for charges whose extracted code fields flag them as 'no charge' (CS='NC'), cosmetic (CT like COS/S9999MN), or specific vision codes (V2786F/V2787F/V27878F), it returns the billed charge as-is (or zero when the billed charge is itself zero) instead of running normal fee-schedule pricing.
  2. custom SQL — Pays three related ophthalmic codes (V2785, V2790 corneal tissue, J1097 compounded drug) at full billed charges for dates of service on/after 1/1/2018.
  3. 100% of the APC-Rates fee schedule
Adjustments — all apply, in order
  1. modifier 1 present → 0% of the running amount
  2. modifier Y present → 0% of the running amount
  3. modifier 50 present → 150% of the running amount
  4. modifier 54 present → 80% of the running amount
  5. zero out charges excluded by the Bundled-Procedures schedule
  6. cap each charge and the account total at 100% of billed charges
  7. multiple-surgery reduction (contract rules) — pays 100/50%
  8. multiple-surgery reduction (contract rules) — pays 100/0%
PreferredOne-ASC-20224 base · 8 adj
PreferredOne
Facility · Hospital/ASC · 2022-01-01 → 2999-12-31
Base terms — first match wins
  1. custom SQL — A cosmetic/no-charge carve-out override: for charges whose extracted code fields flag them as 'no charge' (CS='NC'), cosmetic (CT like COS/S9999MN), or specific vision codes (V2786F/V2787F/V27878F), it returns the billed charge as-is (or zero when the billed charge is itself zero) instead of running normal fee-schedule pricing.
  2. 100% of the Carve-Outs fee schedule
  3. custom SQL — Pays three related ophthalmic codes (V2785, V2790 corneal tissue, J1097 compounded drug) at full billed charges for dates of service on/after 1/1/2018.
  4. 100% of the APC-Rates fee schedule
Adjustments — all apply, in order
  1. modifier 1 present → 0% of the running amount
  2. modifier Y present → 0% of the running amount
  3. modifier 50 present → 150% of the running amount
  4. modifier 54 present → 80% of the running amount
  5. zero out charges excluded by the Bundled-Procedures schedule
  6. cap each charge and the account total at 100% of billed charges
  7. multiple-surgery reduction (contract rules) — pays 100/50%
  8. multiple-surgery reduction (contract rules) — pays 100/0%
PreferredOne-PPO6 base · 8 adj
Aetna
Profee · all facilities · 2017-01-01 → 2023-02-28
PreferredOne PPO
Profee · all facilities · 2017-01-01 → 2099-12-31
Base terms — first match wins
  1. custom SQL — A cosmetic/no-charge carve-out override: for charges whose extracted code fields flag them as 'no charge' (CS='NC'), cosmetic (CT like COS/S9999MN), or specific vision codes (V2786F/V2787F/V27878F), it returns the billed charge as-is (or zero when the billed charge is itself zero) instead of running normal fee-schedule pricing.
  2. custom SQL — A flat 65% of billed charges override for three specific procedure codes, one of which (0402T) overlaps with the 60%-override snippet 232039445d905101 for a different customer/config.
  3. custom SQL — Optometry fee-schedule lookup that selects between a 'Optometry-Hospital' vs 'Optometry-Clinic' schedule based on the charge's place-of-service (via a secondary POS-Code-Indicators schedule), then returns the matching fee * Units. — when PrimaryCare Primary Care is present
  4. custom SQL — Optometry fee-schedule lookup that selects between a 'Optometry-Hospital' vs 'Optometry-Clinic' schedule based on the charge's place-of-service (via a secondary POS-Code-Indicators schedule), then returns the matching fee * Units. — when Optometrist Optometrist is present
  5. custom SQL — Looks up a per-unit fee from a facility/insurance/date-scoped 'Profee' fee schedule keyed by revenue/CPT code and modifier, adjusted for place-of-service (facility vs non-facility via a POS-code-indicator schedule), times units -- this is the canonical PercentOfFees pricing pattern reimplemented as raw admin SQL.
  6. custom SQL — Looks up a fee from the customer's own Fixed-Fees-Hospital/Fixed-Fees-Clinic schedule by charge-type code and modifier filter, picking the highest-priority matching record, with the facility-vs-clinic dimension resolved from an explicit POS code on the charge or, failing that, inferred from the facility name containing 'ASC'; multiplies by units.
Adjustments — all apply, in order
  1. modifier 1 present → 0% of the running amount
  2. modifier Y present → 0% of the running amount
  3. modifier 50 present → 150% of the running amount
  4. modifier 52 present → 50% of the running amount
  5. modifier 54 present → 80% of the running amount
  6. modifier 78 present → 70% of the running amount
  7. cap each charge and the account total at 100% of billed charges
  8. multiple-procedure reduction (contract rules) — base codes 2, 3; pays 100/50%
PreferredOne-PPO-20164 base · 8 adj
PreferredOne PPO
Profee · all facilities · 2016-01-01 → 2016-12-31
Base terms — first match wins
  1. custom SQL — A cosmetic/no-charge carve-out override: for charges whose extracted code fields flag them as 'no charge' (CS='NC'), cosmetic (CT like COS/S9999MN), or specific vision codes (V2786F/V2787F/V27878F), it returns the billed charge as-is (or zero when the billed charge is itself zero) instead of running normal fee-schedule pricing.
  2. custom SQL — Optometry fee-schedule lookup that selects between a 'Optometry-Hospital' vs 'Optometry-Clinic' schedule based on the charge's place-of-service (via a secondary POS-Code-Indicators schedule), then returns the matching fee * Units. — when PrimaryCare Primary Care is present
  3. custom SQL — Optometry fee-schedule lookup that selects between a 'Optometry-Hospital' vs 'Optometry-Clinic' schedule based on the charge's place-of-service (via a secondary POS-Code-Indicators schedule), then returns the matching fee * Units. — when Optometrist Optometrist is present
  4. custom SQL — Looks up a per-unit fee from a facility/insurance/date-scoped 'Profee' fee schedule keyed by revenue/CPT code and modifier, adjusted for place-of-service (facility vs non-facility via a POS-code-indicator schedule), times units -- this is the canonical PercentOfFees pricing pattern reimplemented as raw admin SQL.
Adjustments — all apply, in order
  1. modifier 1 present → 0% of the running amount
  2. modifier Y present → 0% of the running amount
  3. modifier 50 present → 150% of the running amount
  4. modifier 52 present → 50% of the running amount
  5. modifier 54 present → 80% of the running amount
  6. modifier 78 present → 70% of the running amount
  7. cap each charge and the account total at 100% of billed charges
  8. multiple-procedure reduction (contract rules) — base codes 2, 3; pays 100/50%
PreferredOne-PPO-ASC2 base · 4 adj
Aetna, PreferredOne PPO
Facility · Hospital/ASC · 2017-01-01 → 2019-12-31
Base terms — first match wins
  1. custom SQL — A cosmetic/no-charge carve-out override: for charges whose extracted code fields flag them as 'no charge' (CS='NC'), cosmetic (CT like COS/S9999MN), or specific vision codes (V2786F/V2787F/V27878F), it returns the billed charge as-is (or zero when the billed charge is itself zero) instead of running normal fee-schedule pricing.
  2. 65% of billed charges
Adjustments — all apply, in order
  1. modifier 1 present → 0% of the running amount
  2. modifier Y present → 0% of the running amount
  3. modifier 54 present → 80% of the running amount
  4. custom SQL — Pays two corneal/ophthalmic codes (V2785, V2790) at full billed charges unconditionally, with no date restriction.
PreferredOne-PPO-ASC-20202 base · 4 adj
Aetna, PreferredOne PPO
Facility · Hospital/ASC · 2020-01-01 → 2020-12-31
Base terms — first match wins
  1. custom SQL — A cosmetic/no-charge carve-out override: for charges whose extracted code fields flag them as 'no charge' (CS='NC'), cosmetic (CT like COS/S9999MN), or specific vision codes (V2786F/V2787F/V27878F), it returns the billed charge as-is (or zero when the billed charge is itself zero) instead of running normal fee-schedule pricing.
  2. 68% of billed charges
Adjustments — all apply, in order
  1. modifier 1 present → 0% of the running amount
  2. modifier Y present → 0% of the running amount
  3. modifier 54 present → 80% of the running amount
  4. custom SQL — Pays two corneal/ophthalmic codes (V2785, V2790) at full billed charges unconditionally, with no date restriction.
PreferredOne-PPO-ASC-20212 base · 4 adj
Aetna, PreferredOne PPO
Facility · Hospital/ASC · 2021-01-01 → 2021-12-31
Base terms — first match wins
  1. custom SQL — A cosmetic/no-charge carve-out override: for charges whose extracted code fields flag them as 'no charge' (CS='NC'), cosmetic (CT like COS/S9999MN), or specific vision codes (V2786F/V2787F/V27878F), it returns the billed charge as-is (or zero when the billed charge is itself zero) instead of running normal fee-schedule pricing.
  2. 70% of billed charges
Adjustments — all apply, in order
  1. modifier 1 present → 0% of the running amount
  2. modifier Y present → 0% of the running amount
  3. modifier 54 present → 80% of the running amount
  4. custom SQL — Pays two corneal/ophthalmic codes (V2785, V2790) at full billed charges unconditionally, with no date restriction.
PreferredOne-PPO-ASC-20222 base · 4 adj
Aetna, PreferredOne PPO
Facility · Hospital/ASC · 2022-01-01 → 2022-12-31
Base terms — first match wins
  1. custom SQL — A cosmetic/no-charge carve-out override: for charges whose extracted code fields flag them as 'no charge' (CS='NC'), cosmetic (CT like COS/S9999MN), or specific vision codes (V2786F/V2787F/V27878F), it returns the billed charge as-is (or zero when the billed charge is itself zero) instead of running normal fee-schedule pricing.
  2. 71.5% of billed charges
Adjustments — all apply, in order
  1. modifier 1 present → 0% of the running amount
  2. modifier Y present → 0% of the running amount
  3. modifier 54 present → 80% of the running amount
  4. custom SQL — Pays the full billed charge as allowed, with no discount, for three specific codes (V2785, V2627, C1839).
PreferredOne-PPO-ASC-20232 base · 5 adj
Aetna
Facility · Hospital/ASC · 2023-01-01 → 2023-02-28
PreferredOne PPO
Facility · Hospital/ASC · 2023-01-01 → 2099-12-31
Base terms — first match wins
  1. custom SQL — A cosmetic/no-charge carve-out override: for charges whose extracted code fields flag them as 'no charge' (CS='NC'), cosmetic (CT like COS/S9999MN), or specific vision codes (V2786F/V2787F/V27878F), it returns the billed charge as-is (or zero when the billed charge is itself zero) instead of running normal fee-schedule pricing.
  2. 71.5% of billed charges
Adjustments — all apply, in order
  1. modifier 1 present → 0% of the running amount
  2. modifier Y present → 0% of the running amount
  3. modifier 54 present → 80% of the running amount
  4. custom SQL — Pays the full billed charge as allowed, with no discount, for three specific codes (V2785, V2627, C1839).
  5. cap each charge and the account total at 100% of billed charges
SelectCare/LaborCare3 base · 8 adj
Aetna
Profee · all facilities · 2016-01-01 → 2016-12-31
LaborCare, United Healthcare, United LaborCare
Profee · all facilities · 2016-01-01 → 2018-08-31
SelectCare
Profee · all facilities · 2016-01-01 → 2099-12-31
Base terms — first match wins
  1. custom SQL — A cosmetic/no-charge carve-out override: for charges whose extracted code fields flag them as 'no charge' (CS='NC'), cosmetic (CT like COS/S9999MN), or specific vision codes (V2786F/V2787F/V27878F), it returns the billed charge as-is (or zero when the billed charge is itself zero) instead of running normal fee-schedule pricing.
  2. 100% of the SCLC-Exceptions fee schedule
  3. 103% of the Profee-Clinic fee schedule ⚠︎ named “100% of SelectCare/LaborCare Rates + 3% MN Care Tax” but configured at 103%
Adjustments — all apply, in order
  1. modifier 1 present → 0% of the running amount
  2. modifier Y present → 0% of the running amount
  3. modifier 50 present → 150% of the running amount
  4. modifier 52 present → 50% of the running amount
  5. modifier 54 present → 80% of the running amount
  6. modifier 78 present → 84% of the running amount
  7. cap each charge and the account total at 100% of billed charges
  8. multiple-procedure reduction (contract rules) — base codes 2, 3; pays 100/50%
SelectCare/LaborCare-ASC-20162 base · 2 adj
Aetna, LaborCare, SelectCare, United Healthcare, United LaborCare
Facility · Hospital/ASC · 2016-01-01 → 2016-12-31
Base terms — first match wins
  1. custom SQL — A cosmetic/no-charge carve-out override: for charges whose extracted code fields flag them as 'no charge' (CS='NC'), cosmetic (CT like COS/S9999MN), or specific vision codes (V2786F/V2787F/V27878F), it returns the billed charge as-is (or zero when the billed charge is itself zero) instead of running normal fee-schedule pricing.
  2. 77.2% of billed charges
Adjustments — all apply, in order
  1. modifier 1 present → 0% of the running amount
  2. modifier Y present → 0% of the running amount
SelectCare/LaborCare-ASC-20172 base · 2 adj
LaborCare, United Healthcare, United LaborCare
Facility · Hospital/ASC · 2017-01-01 → 2018-08-31
SelectCare
Facility · Hospital/ASC · 2017-01-01 → 2099-12-31
Base terms — first match wins
  1. custom SQL — A cosmetic/no-charge carve-out override: for charges whose extracted code fields flag them as 'no charge' (CS='NC'), cosmetic (CT like COS/S9999MN), or specific vision codes (V2786F/V2787F/V27878F), it returns the billed charge as-is (or zero when the billed charge is itself zero) instead of running normal fee-schedule pricing.
  2. 76.1% of billed charges
Adjustments — all apply, in order
  1. modifier 1 present → 0% of the running amount
  2. modifier Y present → 0% of the running amount
SelfPay1 base · 1 adj
Self Pay
Facility · Minnesota Eye Consultants, Minnesota Eye Laser And Surgery Centers, Hospital/ASC · 2000-01-01 → 2999-12-31
Self Pay
Profee · Minnesota Eye Consultants, Minnesota Eye Laser And Surgery Centers · 2000-01-01 → 2999-12-31
Base terms — first match wins
  1. 100% of billed charges
Adjustments — all apply, in order
  1. custom SQL — Hardcoded flat fee of $4,220 for HCPCS J2787 (afamelanotide) for dates of service on/after 2023-10-01.
SelfPay-UVP1 base · 1 adj
Self Pay
Facility · Minnesota Retina Associates, Northwest Eye Clinic, Southwest Eye Care, Hospital/ASC · 2000-01-01 → 2999-12-31
Self Pay
Profee · Minnesota Retina Associates, Northwest Eye Clinic, Southwest Eye Care · 2000-01-01 → 2999-12-31
Base terms — first match wins
  1. 70% of billed charges
Adjustments — all apply, in order
  1. custom SQL — Hardcoded flat fee of $4,220 for HCPCS J2787 (afamelanotide) for dates of service on/after 2023-10-01.
UCare-Choices-MN-Sure9 base · 16 adj
UCare Choices MN Sure, Ucare Ind Family Plan
Profee · Minnesota Eye Consultants, Minnesota Eye Laser And Surgery Centers, Southwest Eye Care · 2016-01-01 → 2099-12-31
Base terms — first match wins
  1. 0% of the Non-Covered-Services fee schedule
  2. custom SQL — A cosmetic/no-charge carve-out override: for charges whose extracted code fields flag them as 'no charge' (CS='NC'), cosmetic (CT like COS/S9999MN), or specific vision codes (V2786F/V2787F/V27878F), it returns the billed charge as-is (or zero when the billed charge is itself zero) instead of running normal fee-schedule pricing.
  3. 163.2% of the Medicare-Contractor-Codes fee schedule
  4. 163.2% of the Medicare-Exceptions fee schedule
  5. 163.2% of Medicare drug
  6. 163.2% of Medicare lab
  7. 163.2% of Medicare DME
  8. 160% of Medicare RVU
  9. 163.2% of Medicare ASC
Adjustments — all apply, in order
  1. modifier 1 present → 0% of the running amount
  2. modifier Y present → 0% of the running amount
  3. multiple-endoscopy reduction (contract rules)
  4. rescale by a percentage read from the Mid-Level-Charges schedule — when MidLevelProviders Mid-Level is present
  5. modifier 22 present → 135% of the running amount
  6. modifier 50 present → 150% of the running amount
  7. modifier 52 present → 50% of the running amount
  8. modifier 54 present → 80% of the running amount
  9. modifier 62 present → 62.5% of the running amount
  10. modifier 78 present → 70% of the running amount
  11. modifier 80 present → 16% of the running amount
  12. modifier 81 present → 16% of the running amount
  13. modifier 82 present → 16% of the running amount
  14. modifier AS present → 13.6% of the running amount
  15. cap each charge and the account total at 100% of billed charges
  16. Medicare multiple-procedure reduction — base codes 2, 3; pays 100/50%
UCare-MA-backup1 base · 0 adj
UCare MA
Facility · Hospital/ASC · 2000-01-01 → 2099-12-31
UCare MA
Profee · all facilities · 2000-01-01 → 2099-12-31
Base terms — first match wins
  1. 100% of billed charges
UCare-Seniors9 base · 16 adj
UCare Seniors
Profee · Minnesota Eye Consultants, Minnesota Eye Laser And Surgery Centers, Southwest Eye Care · 2017-01-01 → 2099-12-31
Base terms — first match wins
  1. 0% of the Non-Covered-Services fee schedule
  2. custom SQL — A cosmetic/no-charge carve-out override: for charges whose extracted code fields flag them as 'no charge' (CS='NC'), cosmetic (CT like COS/S9999MN), or specific vision codes (V2786F/V2787F/V27878F), it returns the billed charge as-is (or zero when the billed charge is itself zero) instead of running normal fee-schedule pricing.
  3. 105% of the Medicare-Contractor-Codes fee schedule
  4. 105% of the Medicare-Exceptions fee schedule
  5. 105% of Medicare drug
  6. 105% of Medicare lab
  7. 105% of Medicare DME
  8. 100% of Medicare RVU
  9. 105% of Medicare ASC
Adjustments — all apply, in order
  1. modifier 1 present → 0% of the running amount
  2. modifier Y present → 0% of the running amount
  3. multiple-procedure reduction (contract rules) — base codes 2, 3; pays 100/50%
  4. multiple-endoscopy reduction (contract rules)
  5. rescale by a percentage read from the Mid-Level-Charges schedule — when MidLevelProviders Mid-Level is present
  6. modifier 22 present → 135% of the running amount
  7. modifier 50 present → 150% of the running amount
  8. modifier 52 present → 50% of the running amount
  9. modifier 54 present → 80% of the running amount
  10. modifier 62 present → 62.5% of the running amount
  11. modifier 78 present → 70% of the running amount
  12. modifier 80 present → 16% of the running amount
  13. modifier 81 present → 16% of the running amount
  14. modifier 82 present → 16% of the running amount
  15. modifier AS present → 13.6% of the running amount
  16. cap each charge and the account total at 100% of billed charges
UCare-Seniors-20168 base · 16 adj
UCare Seniors
Profee · all facilities · 2016-01-01 → 2016-12-31
Base terms — first match wins
  1. 0% of the Non-Covered-Services fee schedule
  2. custom SQL — A cosmetic/no-charge carve-out override: for charges whose extracted code fields flag them as 'no charge' (CS='NC'), cosmetic (CT like COS/S9999MN), or specific vision codes (V2786F/V2787F/V27878F), it returns the billed charge as-is (or zero when the billed charge is itself zero) instead of running normal fee-schedule pricing.
  3. 105% of the Medicare-Contractor-Codes fee schedule
  4. 105% of the Medicare-Drug fee schedule
  5. 105% of the Medicare-Lab fee schedule
  6. 105% of the Medicare-DME fee schedule
  7. custom SQL — Looks up a Medicare RVU fee (Hospital vs Clinic schedule chosen via a POS-code-indicator lookup keyed off facility type/place-of-service) for the charge's code, multiplies by units and a flat 1.05 uplift.
  8. 105% of the Medicare-ASC fee schedule
Adjustments — all apply, in order
  1. modifier 1 present → 0% of the running amount
  2. modifier Y present → 0% of the running amount
  3. multiple-endoscopy reduction (contract rules)
  4. rescale by a percentage read from the Mid-Level-Charges schedule — when MidLevelProviders Mid-Level is present
  5. modifier 22 present → 135% of the running amount
  6. modifier 50 present → 150% of the running amount
  7. modifier 52 present → 50% of the running amount
  8. modifier 54 present → 80% of the running amount
  9. modifier 62 present → 62.5% of the running amount
  10. modifier 78 present → 70% of the running amount
  11. modifier 80 present → 16% of the running amount
  12. modifier 81 present → 16% of the running amount
  13. modifier 82 present → 16% of the running amount
  14. modifier AS present → 13.6% of the running amount
  15. cap each charge and the account total at 100% of billed charges
  16. multiple-procedure reduction (contract rules) — base codes 2, 3; pays 100/50%
UCare-Seniors-BackUp9 base · 16 adj
UCare Seniors
Profee · all facilities · 2017-01-01 → 2099-12-31
Base terms — first match wins
  1. 0% of the Non-Covered-Services fee schedule
  2. custom SQL — Cosmetic/no-charge carve-out override, same family as hash ca6756740e819542 (index 2) but missing that snippet's fourth block for the specific V27xx vision codes: pays full billed charge for 'NC' or cosmetic (COS/S9999MN) coded lines, zeroing cosmetic lines with $0 charge.
  3. 105% of the Medicare-Contractor-Codes fee schedule
  4. 105% of the Medicare-Exceptions fee schedule
  5. 105% of the Medicare-Drug fee schedule
  6. 105% of the Medicare-Lab fee schedule
  7. 105% of the Medicare-DME fee schedule
  8. custom SQL — Looks up a Medicare RVU fee (Hospital vs Clinic schedule chosen via a POS-code-indicator lookup keyed off facility type/place-of-service) for the charge's code, multiplies by units and a flat 1.05 uplift.
  9. 105% of the Medicare-ASC fee schedule
Adjustments — all apply, in order
  1. modifier 1 present → 0% of the running amount
  2. modifier Y present → 0% of the running amount
  3. multiple-endoscopy reduction (contract rules)
  4. rescale by a percentage read from the Mid-Level-Charges schedule — when MidLevelProviders Mid-Level is present
  5. modifier 22 present → 135% of the running amount
  6. modifier 50 present → 150% of the running amount
  7. modifier 52 present → 50% of the running amount
  8. modifier 54 present → 80% of the running amount
  9. modifier 62 present → 62.5% of the running amount
  10. modifier 78 present → 70% of the running amount
  11. modifier 80 present → 16% of the running amount
  12. modifier 81 present → 16% of the running amount
  13. modifier 82 present → 16% of the running amount
  14. modifier AS present → 13.6% of the running amount
  15. cap each charge and the account total at 100% of billed charges
  16. multiple-procedure reduction (contract rules) — base codes 2, 3; pays 100/50%
UCare-Seniors-UVP9 base · 16 adj
UCare Seniors
Profee · Minnesota Retina Associates, Northwest Eye Clinic · 2017-01-01 → 2099-12-31
Base terms — first match wins
  1. 0% of the Non-Covered-Services fee schedule
  2. custom SQL — A cosmetic/no-charge carve-out override: for charges whose extracted code fields flag them as 'no charge' (CS='NC'), cosmetic (CT like COS/S9999MN), or specific vision codes (V2786F/V2787F/V27878F), it returns the billed charge as-is (or zero when the billed charge is itself zero) instead of running normal fee-schedule pricing.
  3. 105% of the Medicare-Contractor-Codes fee schedule
  4. 105% of the Medicare-Exceptions fee schedule
  5. 108% of Medicare drug
  6. 108% of Medicare lab
  7. 108% of Medicare DME
  8. 108% of Medicare RVU
  9. 100% of the Medicare-MPFSP fee schedule
Adjustments — all apply, in order
  1. modifier 1 present → 0% of the running amount
  2. modifier Y present → 0% of the running amount
  3. multiple-procedure reduction (contract rules) — base codes 2, 3; pays 100/50%
  4. multiple-endoscopy reduction (contract rules)
  5. rescale by a percentage read from the Mid-Level-Charges schedule — when MidLevelProviders Mid-Level is present
  6. modifier 22 present → 135% of the running amount
  7. modifier 50 present → 150% of the running amount
  8. modifier 52 present → 50% of the running amount
  9. modifier 54 present → 80% of the running amount
  10. modifier 62 present → 62.5% of the running amount
  11. modifier 78 present → 70% of the running amount
  12. modifier 80 present → 16% of the running amount
  13. modifier 81 present → 16% of the running amount
  14. modifier 82 present → 16% of the running amount
  15. modifier AS present → 13.6% of the running amount
  16. cap each charge and the account total at 100% of billed charges
UCare-UVP-Choices-MN-Sure9 base · 16 adj
Ucare Ind Family Plan
Profee · Minnesota Retina Associates, Northwest Eye Clinic · 2023-01-01 → 2099-12-31
Base terms — first match wins
  1. 0% of the Non-Covered-Services fee schedule
  2. custom SQL — A cosmetic/no-charge carve-out override: for charges whose extracted code fields flag them as 'no charge' (CS='NC'), cosmetic (CT like COS/S9999MN), or specific vision codes (V2786F/V2787F/V27878F), it returns the billed charge as-is (or zero when the billed charge is itself zero) instead of running normal fee-schedule pricing.
  3. 163.2% of the Medicare-Contractor-Codes fee schedule
  4. 163.2% of the Medicare-Exceptions fee schedule
  5. 278% of Medicare drug
  6. 278% of Medicare lab
  7. 278% of Medicare DME
  8. 278% of Medicare RVU
  9. 278% of Medicare ASC
Adjustments — all apply, in order
  1. modifier 1 present → 0% of the running amount
  2. modifier Y present → 0% of the running amount
  3. multiple-endoscopy reduction (contract rules)
  4. rescale by a percentage read from the Mid-Level-Charges schedule — when MidLevelProviders Mid-Level is present
  5. modifier 22 present → 135% of the running amount
  6. modifier 50 present → 150% of the running amount
  7. modifier 52 present → 50% of the running amount
  8. modifier 54 present → 80% of the running amount
  9. modifier 62 present → 62.5% of the running amount
  10. modifier 78 present → 70% of the running amount
  11. modifier 80 present → 16% of the running amount
  12. modifier 81 present → 16% of the running amount
  13. modifier 82 present → 16% of the running amount
  14. modifier AS present → 13.6% of the running amount
  15. cap each charge and the account total at 100% of billed charges
  16. multiple-procedure reduction (contract rules) — base codes 2, 3; pays 100/50%
Ucare-Ind-Family-Plan-ASC5 base · 8 adj
Ucare Ind Family Plan
Facility · Hospital/ASC · 2016-01-01 → 2099-12-31
Base terms — first match wins
  1. 0% of the Non-Covered-Services fee schedule
  2. custom SQL — A cosmetic/no-charge carve-out override: for charges whose extracted code fields flag them as 'no charge' (CS='NC'), cosmetic (CT like COS/S9999MN), or specific vision codes (V2786F/V2787F/V27878F), it returns the billed charge as-is (or zero when the billed charge is itself zero) instead of running normal fee-schedule pricing.
  3. custom SQL — For HCPCS V2785 (corneal tissue processing) charges, sets the allowed amount to 122.16% of the billed charge -- a fixed contractual markup for one code.
  4. 122.16% of Medicare ASC
  5. flat $0
Adjustments — all apply, in order
  1. custom SQL — Pays the compounded ophthalmic drug J1097 at full billed charges for dates of service on/after 1/1/2019 (a drug not otherwise represented on a standard fee schedule).
  2. modifier 1 present → 0% of the running amount
  3. modifier Y present → 0% of the running amount
  4. multiple-endoscopy reduction (contract rules)
  5. modifier 50 present → 150% of the running amount
  6. modifier 52 present → 50% of the running amount
  7. cap each charge and the account total at 100% of billed charges
  8. multiple-surgery reduction (contract rules) — pays 100/50%
Ucare-Ind-Family-Plan-ASC-BackUp5 base · 8 adj
Ucare Ind Family Plan
Facility · Hospital/ASC · 2016-01-01 → 2099-12-31
Base terms — first match wins
  1. 0% of the Non-Covered-Services fee schedule
  2. custom SQL — Cosmetic/no-charge carve-out override, same family as hash ca6756740e819542 (index 2) but missing that snippet's fourth block for the specific V27xx vision codes: pays full billed charge for 'NC' or cosmetic (COS/S9999MN) coded lines, zeroing cosmetic lines with $0 charge.
  3. custom SQL — For HCPCS V2785 (corneal tissue processing) charges, sets the allowed amount to 122.16% of the billed charge -- a fixed contractual markup for one code.
  4. 122.16% of the Medicare-ASC fee schedule
  5. flat $0
Adjustments — all apply, in order
  1. custom SQL — Pays the compounded ophthalmic drug J1097 at full billed charges for dates of service on/after 1/1/2019 (a drug not otherwise represented on a standard fee schedule).
  2. modifier 1 present → 0% of the running amount
  3. modifier Y present → 0% of the running amount
  4. multiple-endoscopy reduction (contract rules)
  5. modifier 50 present → 150% of the running amount
  6. modifier 52 present → 50% of the running amount
  7. cap each charge and the account total at 100% of billed charges
  8. multiple-surgery reduction (contract rules) — pays 100/50%
UnitedHealthcare-2018-095 base · 9 adj
BIND, GEHA, LaborCare, Surest, UMR, United Healthcare, United LaborCare
Profee · Minnesota Eye Consultants, Minnesota Eye Laser And Surgery Centers · 2018-09-01 → 2021-10-31
Base terms — first match wins
  1. custom SQL — A cosmetic/no-charge carve-out override: for charges whose extracted code fields flag them as 'no charge' (CS='NC'), cosmetic (CT like COS/S9999MN), or specific vision codes (V2786F/V2787F/V27878F), it returns the billed charge as-is (or zero when the billed charge is itself zero) instead of running normal fee-schedule pricing.
  2. 100% of the UHC-MEC-Profee-CarveOut fee schedule
  3. 100% of the SCLC-Exceptions fee schedule
  4. 100% of the RVU-Based-Hospital fee schedule — when PlaceOfService 11 is absent
  5. 100% of the RVU-Based-Clinic fee schedule — when PlaceOfService 11 is present
Adjustments — all apply, in order
  1. modifier 1 present → 0% of the running amount
  2. modifier Y present → 0% of the running amount
  3. modifier 50 present → 150% of the running amount
  4. modifier 52 present → 25% of the running amount
  5. modifier 54 present → 80% of the running amount
  6. modifier 78 present → 70% of the running amount
  7. modifier 80 present → 84% of the running amount
  8. multiple-procedure reduction (contract rules) — base codes 2, 3; pays 100/50%
  9. cap each charge and the account total at 100% of billed charges
UnitedHealthcare-2021-117 base · 10 adj
BIND, GEHA, LaborCare, Surest, UMR, United Healthcare, United LaborCare
Profee · Minnesota Eye Consultants, Minnesota Eye Laser And Surgery Centers · 2021-11-01 → 2099-12-31
Base terms — first match wins
  1. custom SQL — A cosmetic/no-charge carve-out override: for charges whose extracted code fields flag them as 'no charge' (CS='NC'), cosmetic (CT like COS/S9999MN), or specific vision codes (V2786F/V2787F/V27878F), it returns the billed charge as-is (or zero when the billed charge is itself zero) instead of running normal fee-schedule pricing.
  2. custom SQL — Hardcodes a flat $730 base allowed amount for HCPCS S0812 (hearing-aid related code) for service dates on/after 2024-01-01; a single ticket-driven override.
  3. 100% of the Fixed-Fees-Hospital fee schedule — when PlaceOfService 11 is absent
  4. 100% of the Fixed-Fees-Clinic fee schedule — when PlaceOfService 11 is present
  5. 100% of the Carve-Outs fee schedule
  6. 100% of the RVU-Based-Hospital fee schedule — when PlaceOfService 11 is absent
  7. 100% of the RVU-Based-Clinic fee schedule — when PlaceOfService 11 is present
Adjustments — all apply, in order
  1. modifier 1 present → 0% of the running amount
  2. modifier Y present → 0% of the running amount
  3. modifier 50 present → 150% of the running amount
  4. modifier 52 present → 25% of the running amount
  5. modifier 54 present → 80% of the running amount
  6. modifier 78 present → 70% of the running amount
  7. modifier 80 present → 84% of the running amount
  8. multiple-procedure reduction (contract rules) — base codes 2, 3; pays 100/50%
  9. cap each charge and the account total at 100% of billed charges
  10. custom SQL — Applies a flat 15% discount to the already-computed allowed amount whenever the rendering provider's specialty (looked up by ProviderID) is 'Primary Care'.
UnitedHealthcare-ASC-2018-093 base · 5 adj
BIND, GEHA, LaborCare, Oxford Health Plan, Surest, UMR, United Healthcare, United LaborCare
Facility · Hospital/ASC · 2018-09-01 → 2025-03-31
Base terms — first match wins
  1. custom SQL — A cosmetic/no-charge carve-out override: for charges whose extracted code fields flag them as 'no charge' (CS='NC'), cosmetic (CT like COS/S9999MN), or specific vision codes (V2786F/V2787F/V27878F), it returns the billed charge as-is (or zero when the billed charge is itself zero) instead of running normal fee-schedule pricing.
  2. 100% of the Carve-Outs fee schedule
  3. 100% of the OPG-Rate fee schedule
Adjustments — all apply, in order
  1. modifier 50 present → 150% of the running amount
  2. modifier 1 present → 0% of the running amount
  3. modifier Y present → 0% of the running amount
  4. multiple-surgery reduction (contract rules) — pays 100/50/25/0%
  5. cap each charge and the account total at 100% of billed charges
UnitedHealthcare-ASC-2025-043 base · 5 adj
BIND, GEHA, LaborCare, Oxford Health Plan, Surest, UMR, United Healthcare, United LaborCare
Facility · Hospital/ASC · 2025-04-01 → 2099-12-31
Base terms — first match wins
  1. custom SQL — A cosmetic/no-charge carve-out override: for charges whose extracted code fields flag them as 'no charge' (CS='NC'), cosmetic (CT like COS/S9999MN), or specific vision codes (V2786F/V2787F/V27878F), it returns the billed charge as-is (or zero when the billed charge is itself zero) instead of running normal fee-schedule pricing.
  2. 100% of the Carve-Outs fee schedule
  3. 100% of the OPG-Rate fee schedule
Adjustments — all apply, in order
  1. modifier 50 present → 150% of the running amount
  2. modifier 1 present → 0% of the running amount
  3. modifier Y present → 0% of the running amount
  4. multiple-surgery reduction (contract rules) — pays 100/50/0%
  5. cap each charge and the account total at 100% of billed charges
UnitedHealthcare-SWEC-Profee-Clinic4 base · 9 adj
BIND, GEHA, LaborCare, Oxford Health Plan, Surest, UMR, United Healthcare, United LaborCare
Profee · Southwest Eye Care, Clinic · 2023-07-01 → 2099-12-31
Base terms — first match wins
  1. custom SQL — A cosmetic/no-charge carve-out override: for charges whose extracted code fields flag them as 'no charge' (CS='NC'), cosmetic (CT like COS/S9999MN), or specific vision codes (V2786F/V2787F/V27878F), it returns the billed charge as-is (or zero when the billed charge is itself zero) instead of running normal fee-schedule pricing.
  2. 100% of the Optometry-Clinic-UVP fee schedule — when Optometrist Optometrist is present
  3. 100% of the UVP-Profee-Clinic fee schedule
  4. 60% of billed charges
Adjustments — all apply, in order
  1. modifier 1 present → 0% of the running amount
  2. modifier Y present → 0% of the running amount
  3. rescale by a percentage read from the Mid-Level-Charges schedule — when MidLevelProviders Mid-Level is present
  4. modifier 50 present → 150% of the running amount
  5. modifier 52 present → 50% of the running amount
  6. modifier 54 present → 80% of the running amount
  7. modifier 78 present → 84% of the running amount
  8. multiple-procedure reduction (contract rules) — base codes 2, 3; pays 100/50%
  9. cap each charge and the account total at 100% of billed charges
UnitedHealthcare-SWEC-Profee-Hospital4 base · 9 adj
BIND, GEHA, LaborCare, Oxford Health Plan, Surest, UMR, United Healthcare, United LaborCare
Profee · Southwest Eye Care, Hospital/ASC · 2023-07-01 → 2099-12-31
Base terms — first match wins
  1. custom SQL — A cosmetic/no-charge carve-out override: for charges whose extracted code fields flag them as 'no charge' (CS='NC'), cosmetic (CT like COS/S9999MN), or specific vision codes (V2786F/V2787F/V27878F), it returns the billed charge as-is (or zero when the billed charge is itself zero) instead of running normal fee-schedule pricing.
  2. 100% of the Optometry-Hospital-UVP fee schedule — when Optometrist Optometrist is present
  3. 100% of the UVP-Profee-Hospital fee schedule
  4. 60% of billed charges
Adjustments — all apply, in order
  1. modifier 1 present → 0% of the running amount
  2. modifier Y present → 0% of the running amount
  3. rescale by a percentage read from the Mid-Level-Charges schedule — when MidLevelProviders Mid-Level is present
  4. modifier 50 present → 150% of the running amount
  5. modifier 52 present → 50% of the running amount
  6. modifier 54 present → 80% of the running amount
  7. modifier 78 present → 84% of the running amount
  8. multiple-procedure reduction (contract rules) — base codes 2, 3; pays 100/50%
  9. cap each charge and the account total at 100% of billed charges
UnitedHealthcare-UVP-Profee5 base · 9 adj
BIND, GEHA, LaborCare, Oxford Health Plan, Surest, UMR, United Healthcare, United LaborCare
Profee · Minnesota Retina Associates, Northwest Eye Clinic · 2021-11-01 → 2099-12-31
Base terms — first match wins
  1. custom SQL — A cosmetic/no-charge carve-out override: for charges whose extracted code fields flag them as 'no charge' (CS='NC'), cosmetic (CT like COS/S9999MN), or specific vision codes (V2786F/V2787F/V27878F), it returns the billed charge as-is (or zero when the billed charge is itself zero) instead of running normal fee-schedule pricing.
  2. 100% of the UVP-Profee-Clinic fee schedule — when PlaceOfService 11 is present
  3. 100% of the UVP-Profee-Hospital fee schedule
  4. 100% of Medicare drug
  5. 60% of billed charges
Adjustments — all apply, in order
  1. modifier 1 present → 0% of the running amount
  2. modifier Y present → 0% of the running amount
  3. rescale by a percentage read from the Mid-Level-Charges schedule — when MidLevelProviders Mid-Level is present
  4. modifier 50 present → 150% of the running amount
  5. modifier 52 present → 50% of the running amount
  6. modifier 54 present → 80% of the running amount
  7. modifier 78 present → 84% of the running amount
  8. multiple-procedure reduction (contract rules) — base codes 2, 3; pays 100/50%
  9. cap each charge and the account total at 100% of billed charges

Cannot fire (17)

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

Aetna Allina Health Senior Plan · no contract map10 base · 17 adj
no contract map — cannot be resolved
Base terms — first match wins
  1. 0% of the Non-Covered-Services fee schedule
  2. custom SQL — Cosmetic/no-charge carve-out override, same family as hash ca6756740e819542 (index 2) but missing that snippet's fourth block for the specific V27xx vision codes: pays full billed charge for 'NC' or cosmetic (COS/S9999MN) coded lines, zeroing cosmetic lines with $0 charge.
  3. 100% of the Medicare-Contractor-Codes fee schedule
  4. 100% of the Medicare-Exceptions fee schedule
  5. 100% of the Medicare-Drug fee schedule
  6. 100% of the Medicare-Lab fee schedule
  7. 100% of the Medicare-DME fee schedule
  8. custom SQL — A flat fee-schedule lookup labeled 'Medicare-RVU-Hospital'/'Medicare-RVU-Clinic' that selects a schedule row by facility type, returning fee * Units — despite the name, this does not compute an actual Medicare RVU price, it's a plain customer-maintained fee schedule.
  9. 100% of the Medicare-ASC fee schedule
  10. flat $0
Adjustments — all apply, in order
  1. custom SQL — Hardcoded flat fees for CPT 92015 (refraction) that vary by calendar year: $19.40 for 2019, $19.94 for 2020, $19.41 for 2021.
  2. modifier 1 present → 0% of the running amount
  3. modifier Y present → 0% of the running amount
  4. multiple-endoscopy reduction (contract rules)
  5. multiple-procedure reduction (contract rules) — base codes 2, 3; pays 100/50%
  6. rescale by a percentage read from the Mid-Level-Charges schedule — when MidLevelProviders Mid-Level is present
  7. modifier 22 present → 135% of the running amount
  8. modifier 50 present → 150% of the running amount
  9. modifier 52 present → 50% of the running amount
  10. modifier 54 present → 80% of the running amount
  11. modifier 62 present → 62.5% of the running amount
  12. modifier 78 present → 70% of the running amount
  13. modifier 80 present → 16% of the running amount
  14. modifier 81 present → 16% of the running amount
  15. modifier 82 present → 16% of the running amount
  16. modifier AS present → 13.6% of the running amount
  17. cap each charge and the account total at 100% of billed charges
First-Health-Copy · no contract map7 base · 5 adj
no contract map — cannot be resolved
Base terms — first match wins
  1. 0% of the Non-Covered-Services fee schedule
  2. custom SQL — Pays the full billed charge when the composite charge-status flag ('CS') equals 'NC'; otherwise returns no result.
  3. 210% of the Medicare-Drug fee schedule
  4. 210% of the Medicare-Lab fee schedule
  5. 210% of the Medicare-DME fee schedule
  6. custom SQL — A Medicare-RVU fee-schedule amount for the charge's ChargeType, scaled by units and a flat 2.1x multiplier, where the fee schedule selected (Hospital vs Clinic RVU table) depends on the place-of-service resolved either from the charge's POS code or a facility-name heuristic ('%ASC' suffix implies POS 24).
  7. flat $0
Adjustments — all apply, in order
  1. multiple-procedure reduction (contract rules) — base codes 2; pays 100/50%
  2. rescale by a percentage read from the Mid-Level-Charges schedule — when MidLevelProviders Mid-Level is present
  3. modifier 50 present → 150% of the running amount
  4. modifier 54 present → 70% of the running amount
  5. cap each charge and the account total at 100% of billed charges
HealthPartners MSHO-2018 · no contract map10 base · 16 adj
no contract map — cannot be resolved
Base terms — first match wins
  1. 0% of the Non-Covered-Services fee schedule
  2. custom SQL — A cosmetic/no-charge carve-out override: for charges whose extracted code fields flag them as 'no charge' (CS='NC'), cosmetic (CT like COS/S9999MN), or specific vision codes (V2786F/V2787F/V27878F), it returns the billed charge as-is (or zero when the billed charge is itself zero) instead of running normal fee-schedule pricing.
  3. 100% of the Medicare-Contractor-Codes fee schedule
  4. 100% of the Medicare-Exceptions fee schedule
  5. 100% of Medicare drug
  6. 100% of Medicare lab
  7. 100% of Medicare DME
  8. 100% of Medicare RVU
  9. 100% of Medicare ASC
  10. flat $0
Adjustments — all apply, in order
  1. modifier 1 present → 0% of the running amount
  2. modifier Y present → 0% of the running amount
  3. Medicare multiple-endoscopy reduction
  4. Medicare multiple-procedure reduction — base codes 2, 3; pays 100/50%
  5. rescale by a percentage read from the Mid-Level-Charges schedule — when MidLevelProviders Mid-Level is present
  6. modifier 22 present → 135% of the running amount
  7. modifier 50 present → 150% of the running amount
  8. modifier 52 present → 50% of the running amount
  9. modifier 54 present → 80% of the running amount
  10. modifier 62 present → 62.5% of the running amount
  11. modifier 78 present → 70% of the running amount
  12. modifier 80 present → 16% of the running amount
  13. modifier 81 present → 16% of the running amount
  14. modifier 82 present → 16% of the running amount
  15. modifier AS present → 13.6% of the running amount
  16. cap each charge and the account total at 100% of billed charges
HealthPartners MSHO-ASC-2018 · no contract map5 base · 8 adj
no contract map — cannot be resolved
Base terms — first match wins
  1. 0% of the Non-Covered-Services fee schedule
  2. custom SQL — A cosmetic/no-charge carve-out override: for charges whose extracted code fields flag them as 'no charge' (CS='NC'), cosmetic (CT like COS/S9999MN), or specific vision codes (V2786F/V2787F/V27878F), it returns the billed charge as-is (or zero when the billed charge is itself zero) instead of running normal fee-schedule pricing.
  3. custom SQL — Single-code override, functionally identical to hash 8f8e9be6eea48e6c: for CPT V2785, pay the billed charge in full instead of running normal pricing (with an explicit decimal cast).
  4. 100% of Medicare ASC
  5. flat $0
Adjustments — all apply, in order
  1. custom SQL — Duplicate of idx31/idx45: pays compounded ophthalmic drug J1097 at full billed charges for dates of service on/after 1/1/2019.
  2. modifier 1 present → 0% of the running amount
  3. modifier Y present → 0% of the running amount
  4. Medicare multiple-endoscopy reduction
  5. modifier 50 present → 150% of the running amount
  6. modifier 52 present → 50% of the running amount
  7. cap each charge and the account total at 100% of billed charges
  8. Medicare multiple-surgery reduction — pays 100/50%
HealthPartners-2023-Backup · no contract map4 base · 9 adj
no contract map — cannot be resolved
Base terms — first match wins
  1. 100% of billed charges — when CoverageStatus NC is present
  2. 100% of the Profee-Clinic fee schedule — when PlaceOfService 11 is present
  3. 100% of the Profee-Hospital fee schedule — when PlaceOfService 11 is absent
  4. 70% of billed charges
Adjustments — all apply, in order
  1. modifier 1 present → 0% of the running amount
  2. modifier Y present → 0% of the running amount
  3. modifier 50 present → 200% of the running amount
  4. modifier 52 present → 50% of the running amount
  5. modifier 54 present → 70% of the running amount
  6. Medicare multiple-procedure reduction — base codes 2; pays 100/50%
  7. modifier 50 present → 75% of the running amount
  8. custom SQL — Applies a flat 15% discount to the already-computed allowed amount whenever the rendering provider's specialty (looked up by ProviderID) is 'Primary Care'.
  9. cap each charge and the account total at 100% of billed charges
HealthPartners-FEP-2024 · no contract map4 base · 8 adj
no contract map — cannot be resolved
Base terms — first match wins
  1. custom SQL — A cosmetic/no-charge carve-out override: for charges whose extracted code fields flag them as 'no charge' (CS='NC'), cosmetic (CT like COS/S9999MN), or specific vision codes (V2786F/V2787F/V27878F), it returns the billed charge as-is (or zero when the billed charge is itself zero) instead of running normal fee-schedule pricing.
  2. 100% of the Profee-Clinic fee schedule — when PlaceOfService 11 is present
  3. 100% of the Profee-Hospital fee schedule — when PlaceOfService 11 is absent
  4. 70% of billed charges
Adjustments — all apply, in order
  1. modifier 1 present → 0% of the running amount
  2. modifier Y present → 0% of the running amount
  3. modifier 50 present → 150% of the running amount
  4. modifier 52 present → 50% of the running amount
  5. modifier 54 present → 70% of the running amount
  6. Medicare multiple-procedure reduction — base codes 2, 3; pays 100/50%
  7. custom SQL — Applies a flat 15% discount to the already-computed allowed amount whenever the rendering provider's specialty (looked up by ProviderID) is 'Primary Care'.
  8. cap each charge and the account total at 100% of billed charges
HealthPartners-MA · no contract map3 base · 9 adj
no contract map — cannot be resolved
Base terms — first match wins
  1. custom SQL — A cosmetic/no-charge carve-out override: for charges whose extracted code fields flag them as 'no charge' (CS='NC'), cosmetic (CT like COS/S9999MN), or specific vision codes (V2786F/V2787F/V27878F), it returns the billed charge as-is (or zero when the billed charge is itself zero) instead of running normal fee-schedule pricing.
  2. custom SQL — Professional-fee ('Profee') schedule lookup that selects between 'Profee-Hospital' and 'Profee-Clinic' schedules based on the charge's place-of-service, returning the matching fee * Units.
  3. 70% of billed charges
Adjustments — all apply, in order
  1. modifier 1 present → 0% of the running amount
  2. modifier Y present → 0% of the running amount
  3. rescale by a percentage read from the Mid-Level-Charges schedule — when MidLevelProviders Mid-Level is present
  4. modifier 25 present → 80% of the running amount
  5. modifier 50 present → 150% of the running amount
  6. modifier 52 present → 50% of the running amount
  7. modifier 54 present → 70% of the running amount
  8. Medicare multiple-procedure reduction — base codes 2, 3; pays 100/50%
  9. cap each charge and the account total at 100% of billed charges
Medica Advantage Sol Senior Plan · no contract map9 base · 17 adj
no contract map — cannot be resolved
Base terms — first match wins
  1. 0% of the Non-Covered-Services fee schedule
  2. custom SQL — Cosmetic/no-charge carve-out override, same family as hash ca6756740e819542 (index 2) but missing that snippet's fourth block for the specific V27xx vision codes: pays full billed charge for 'NC' or cosmetic (COS/S9999MN) coded lines, zeroing cosmetic lines with $0 charge.
  3. 100% of the Medicare-Contractor-Codes fee schedule
  4. 100% of the Medicare-Drug fee schedule
  5. 100% of the Medicare-Lab fee schedule
  6. 100% of the Medicare-DME fee schedule
  7. 100% of Medicare RVU
  8. 100% of the Medicare-ASC fee schedule
  9. flat $0
Adjustments — all apply, in order
  1. custom SQL — Flat $19.41 fee for CPT 92015 (refraction), restricted to a fixed 5/1/2020-3/31/2022 date window; returns no row outside that window.
  2. modifier 1 present → 0% of the running amount
  3. modifier Y present → 0% of the running amount
  4. multiple-endoscopy reduction (contract rules)
  5. multiple-procedure reduction (contract rules) — base codes 2, 3; pays 100/50%
  6. rescale by a percentage read from the Mid-Level-Charges schedule — when MidLevelProviders Mid-Level is present
  7. modifier 22 present → 135% of the running amount
  8. modifier 50 present → 150% of the running amount
  9. modifier 52 present → 50% of the running amount
  10. modifier 54 present → 80% of the running amount
  11. modifier 62 present → 62.5% of the running amount
  12. modifier 78 present → 70% of the running amount
  13. modifier 80 present → 16% of the running amount
  14. modifier 81 present → 16% of the running amount
  15. modifier 82 present → 16% of the running amount
  16. modifier AS present → 13.6% of the running amount
  17. cap each charge and the account total at 100% of billed charges
Medica-Dual-2018-Backup · no contract map10 base · 16 adj
no contract map — cannot be resolved
Base terms — first match wins
  1. 0% of the Non-Covered-Services fee schedule
  2. custom SQL — Pays the full billed charge when the composite charge-status flag ('CS') equals 'NC'; otherwise returns no result.
  3. 100% of the Medicare-Contractor-Codes fee schedule
  4. 100% of the Medicare-Exceptions fee schedule
  5. 100% of the Medicare-Drug fee schedule
  6. 100% of the Medicare-Lab fee schedule
  7. 100% of the Medicare-DME fee schedule
  8. custom SQL — A flat fee-schedule lookup labeled 'Medicare-RVU-Hospital'/'Medicare-RVU-Clinic' that selects a schedule row by facility type, returning fee * Units — despite the name, this does not compute an actual Medicare RVU price, it's a plain customer-maintained fee schedule.
  9. 100% of the Medicare-ASC fee schedule
  10. flat $0
Adjustments — all apply, in order
  1. modifier 1 present → 0% of the running amount
  2. modifier Y present → 0% of the running amount
  3. multiple-endoscopy reduction (contract rules)
  4. multiple-procedure reduction (contract rules) — base codes 2; pays 100/50%
  5. rescale by a percentage read from the Mid-Level-Charges schedule — when MidLevelProviders Mid-Level is present
  6. modifier 22 present → 135% of the running amount
  7. modifier 50 present → 150% of the running amount
  8. modifier 52 present → 50% of the running amount
  9. modifier 54 present → 80% of the running amount
  10. modifier 62 present → 62.5% of the running amount
  11. modifier 78 present → 70% of the running amount
  12. modifier 80 present → 16% of the running amount
  13. modifier 81 present → 16% of the running amount
  14. modifier 82 present → 16% of the running amount
  15. modifier AS present → 13.6% of the running amount
  16. cap each charge and the account total at 100% of billed charges
Medica-MA-2020 · no contract map2 base · 9 adj
no contract map — cannot be resolved
Base terms — first match wins
  1. custom SQL — A cosmetic/no-charge carve-out override: for charges whose extracted code fields flag them as 'no charge' (CS='NC'), cosmetic (CT like COS/S9999MN), or specific vision codes (V2786F/V2787F/V27878F), it returns the billed charge as-is (or zero when the billed charge is itself zero) instead of running normal fee-schedule pricing.
  2. custom SQL — Same Profee fee-schedule lookup as idx32/36/44, but with no dedup/tie-break at all across matching schedule rows.
Adjustments — all apply, in order
  1. modifier 1 present → 0% of the running amount
  2. modifier Y present → 0% of the running amount
  3. mid-level provider reduction (by NUCC taxonomy)
  4. modifier 50 present → 150% of the running amount
  5. modifier 52 present → 50% of the running amount
  6. modifier 54 present → 80% of the running amount
  7. modifier 78 present → 84% of the running amount
  8. Medicare multiple-procedure reduction — base codes 2, 3; pays 100/50%
  9. cap each charge and the account total at 100% of billed charges
Medica-Medicare-ASC-2021 · no contract map3 base · 7 adj
no contract map — cannot be resolved
Base terms — first match wins
  1. custom SQL — A cosmetic/no-charge carve-out override: for charges whose extracted code fields flag them as 'no charge' (CS='NC'), cosmetic (CT like COS/S9999MN), or specific vision codes (V2786F/V2787F/V27878F), it returns the billed charge as-is (or zero when the billed charge is itself zero) instead of running normal fee-schedule pricing.
  2. 100% of the Unlisted-Code-Rates fee schedule
  3. 100% of the APC-Rates fee schedule
Adjustments — all apply, in order
  1. modifier 1 present → 0% of the running amount
  2. modifier Y present → 0% of the running amount
  3. modifier 50 present → 150% of the running amount
  4. modifier 52 present → 50% of the running amount
  5. Medicare multiple-surgery reduction — pays 100/50%
  6. custom SQL — For four specific ocular-prosthetic/contact-lens HCPCS codes (L8610, L8612, V2785, V2790), sets allowed to 96.04% of billed charge (0.98 squared).
  7. cap each charge and the account total at 100% of billed charges
Move BCBS from SWE to MNE · contract map selects nothing4 base · 9 adj
— no insurance selected —
— no bill type selected — · — nothing selected — · 2025-11-21 → 2999-12-31
Base terms — first match wins
  1. custom SQL — Cosmetic/no-charge carve-out override, same family as hash ca6756740e819542 (index 2) but missing that snippet's fourth block for the specific V27xx vision codes: pays full billed charge for 'NC' or cosmetic (COS/S9999MN) coded lines, zeroing cosmetic lines with $0 charge.
  2. 101.8% of the Fixed-Fees fee schedule ⚠︎ named “100% of Non-RVU Rates + 1.8% MN Care Tax” but configured at 101.8%
  3. custom SQL — Same Profee fee-schedule lookup as idx32/37/44 (facility/insurance/date-scoped fee by CT code and modifier, POS-adjusted), with an extra flat 1.8% markup baked directly into the query (*1.018).
  4. 100% of Medicare RVU (rates as of 2025-01-01) — when ProviderType in Cardiology
    • CodeRange 99911–99912 → 100%
Adjustments — all apply, in order
  1. modifier 1 present → 0% of the running amount
  2. modifier Y present → 0% of the running amount
  3. rescale by a percentage read from the Mid-Level-Charges schedule — when MidLevelProviders Mid-Level is present
  4. modifier 50 present → 150% of the running amount
  5. modifier 52 present → 90% of the running amount
  6. modifier 54 present → 80% of the running amount
  7. modifier 78 present → 90% of the running amount
  8. multiple-procedure reduction (contract rules) — base codes 2; pays 100/50%
  9. cap each charge and the account total at 100% of billed charges
PreferredOne-ASC-2023 · no contract map4 base · 8 adj
no contract map — cannot be resolved
Base terms — first match wins
  1. custom SQL — A cosmetic/no-charge carve-out override: for charges whose extracted code fields flag them as 'no charge' (CS='NC'), cosmetic (CT like COS/S9999MN), or specific vision codes (V2786F/V2787F/V27878F), it returns the billed charge as-is (or zero when the billed charge is itself zero) instead of running normal fee-schedule pricing.
  2. 100% of the Carve-Outs fee schedule
  3. custom SQL — Pays three related ophthalmic codes (V2785, V2790 corneal tissue, J1097 compounded drug) at full billed charges for dates of service on/after 1/1/2018.
  4. 100% of the APC-Rates fee schedule
Adjustments — all apply, in order
  1. modifier 1 present → 0% of the running amount
  2. modifier Y present → 0% of the running amount
  3. modifier 50 present → 150% of the running amount
  4. modifier 54 present → 80% of the running amount
  5. zero out charges excluded by the Bundled-Procedures schedule
  6. cap each charge and the account total at 100% of billed charges
  7. multiple-surgery reduction (contract rules) — pays 100/50%
  8. multiple-surgery reduction (contract rules) — pays 100/0%
Proposed-Medicare · no contract map10 base · 16 adj
no contract map — cannot be resolved
Base terms — first match wins
  1. 0% of the Non-Covered-Services fee schedule
  2. custom SQL — A bundle of code/status pass-through rules: pays the full charge when a composite 'charge status' flag equals 'NC' (likely non-covered), or when the charge type is a COS/S9999MN service line, or for a fixed list of vision HCPCS codes (V2786F/V2787F/V27878F).
  3. 100% of the Medicare-Contractor-Codes fee schedule
  4. 100% of the Medicare-Exceptions fee schedule
  5. 100% of the Medicare-Drug fee schedule
  6. 100% of the Medicare-Lab fee schedule
  7. 100% of the Medicare-DME fee schedule
  8. custom SQL — A flat fee-schedule lookup labeled 'Medicare-RVU-Hospital'/'Medicare-RVU-Clinic' that selects a schedule row by facility type, returning fee * Units — despite the name, this does not compute an actual Medicare RVU price, it's a plain customer-maintained fee schedule.
  9. 100% of the Medicare-ASC fee schedule
  10. flat $0
Adjustments — all apply, in order
  1. modifier 1 present → 0% of the running amount
  2. modifier Y present → 0% of the running amount
  3. multiple-endoscopy reduction (contract rules)
  4. multiple-procedure reduction (contract rules) — base codes 2, 3; pays 100/50%
  5. rescale by a percentage read from the Mid-Level-Charges schedule — when MidLevelProviders Mid-Level is present
  6. modifier 22 present → 135% of the running amount
  7. modifier 50 present → 150% of the running amount
  8. modifier 52 present → 50% of the running amount
  9. modifier 54 present → 80% of the running amount
  10. modifier 62 present → 62.5% of the running amount
  11. modifier 78 present → 70% of the running amount
  12. modifier 80 present → 16% of the running amount
  13. modifier 81 present → 16% of the running amount
  14. modifier 82 present → 16% of the running amount
  15. modifier AS present → 13.6% of the running amount
  16. cap each charge and the account total at 100% of billed charges
Proposed-Medicare-ASC · no contract map5 base · 8 adj
no contract map — cannot be resolved
Base terms — first match wins
  1. 0% of the Non-Covered-Services fee schedule
  2. custom SQL — A bundle of code/status pass-through rules: pays the full charge when a composite 'charge status' flag equals 'NC' (likely non-covered), or when the charge type is a COS/S9999MN service line, or for a fixed list of vision HCPCS codes (V2786F/V2787F/V27878F).
  3. custom SQL — Single-code override, functionally identical to hash 8f8e9be6eea48e6c: for CPT V2785, pay the billed charge in full instead of running normal pricing (with an explicit decimal cast).
  4. 100% of the Medicare-ASC fee schedule
  5. flat $0
Adjustments — all apply, in order
  1. custom SQL — Pays the compounded ophthalmic drug J1097 at full billed charges for dates of service on/after 1/1/2019 (a drug not otherwise represented on a standard fee schedule).
  2. modifier 1 present → 0% of the running amount
  3. modifier Y present → 0% of the running amount
  4. multiple-endoscopy reduction (contract rules)
  5. modifier 50 present → 150% of the running amount
  6. modifier 52 present → 50% of the running amount
  7. cap each charge and the account total at 100% of billed charges
  8. multiple-surgery reduction (contract rules) — pays 100/50%
UCare-MA · no contract map1 base · 0 adj
no contract map — cannot be resolved
Base terms — first match wins
  1. 100% of billed charges
UnitedHealthcare-SWEC-Profee · no contract map6 base · 9 adj
no contract map — cannot be resolved
Base terms — first match wins
  1. custom SQL — A cosmetic/no-charge carve-out override: for charges whose extracted code fields flag them as 'no charge' (CS='NC'), cosmetic (CT like COS/S9999MN), or specific vision codes (V2786F/V2787F/V27878F), it returns the billed charge as-is (or zero when the billed charge is itself zero) instead of running normal fee-schedule pricing.
  2. 100% of the Optometry-Clinic-UVP fee schedule — when Optometrist Optometrist is present
  3. 100% of the Optometry-Hospital-UVP fee schedule — when Optometrist Optometrist is present
  4. 100% of the UVP-Profee-Clinic fee schedule
  5. 100% of the UVP-Profee-Hospital fee schedule
  6. 60% of billed charges
Adjustments — all apply, in order
  1. modifier 1 present → 0% of the running amount
  2. modifier Y present → 0% of the running amount
  3. rescale by a percentage read from the Mid-Level-Charges schedule — when MidLevelProviders Mid-Level is present
  4. modifier 50 present → 150% of the running amount
  5. modifier 52 present → 50% of the running amount
  6. modifier 54 present → 80% of the running amount
  7. modifier 78 present → 84% of the running amount
  8. multiple-procedure reduction (contract rules) — base codes 2, 3; pays 100/50%
  9. cap each charge and the account total at 100% of billed charges