Customer detail

NWDerm

14
live contracts
0
cannot fire
14
calc types
0
SQL bodies
0
of those blocked
0
map conflicts

Methodology mix

ModifierAdjustment104
LesserOfAdjustment12
MidLevelProviderAdjustment9
MedicareRVU8
MedicareDME8
MedicareMultipleEndoscopyAdjustment8
MedicareMultipleRadiologyAdjustment8
MedicareLab8
MedicareDrug8
MedicareMultipleProcedureAdjustment7
PercentOfFees6
MedicareAnesthesia6
FlatPercentOfCharges5
MedicareBilateralSurgeryAdjustment1

Contracts

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

Aetna-Profee1 base · 18 adj
Aetna
Profee · all facilities · 2022-01-01 → 2999-12-31
Base terms — first match wins
  1. 100% of the Fixed-Fees fee schedule
Adjustments — all apply, in order
  1. Medicare multiple-procedure reduction — base codes 2; pays 100/50% — when Modifier MV is absent
  2. Medicare multiple-endoscopy reduction
  3. Medicare multiple-radiology reduction — base codes 4
  4. mid-level provider reduction (by NUCC taxonomy)
  5. modifier 22 present → 135% of the running amount
  6. modifier 50 present → 150% of the running amount
  7. modifier 52 present → 50% of the running amount
  8. modifier 54 present → 80% of the running amount
  9. modifier 62 present → 62.5% of the running amount
  10. modifier 78 present → 70% of the running amount
  11. modifier 80 present → 16% of the running amount
  12. modifier 81 present → 16% of the running amount
  13. modifier 82 present → 16% of the running amount
  14. modifier AS present → 14% of the running amount
  15. modifier QY present → 50% of the running amount
  16. modifier QK present → 50% of the running amount
  17. modifier QX present → 50% of the running amount
  18. cap each charge and the account total at 100% of billed charges
BCBS-Medicare-Profee4 base · 18 adj
BCBS Medicare
Profee · all facilities · 2022-01-01 → 2999-12-31
Base terms — first match wins
  1. 102% of Medicare lab
  2. 102% of Medicare drug
  3. 102% of Medicare DME
  4. 102% of Medicare RVU
Adjustments — all apply, in order
  1. Medicare multiple-procedure reduction — base codes 2; pays 100/50%
  2. Medicare multiple-endoscopy reduction
  3. Medicare multiple-radiology reduction — base codes 4
  4. mid-level provider reduction (by NUCC taxonomy)
  5. modifier 22 present → 135% of the running amount
  6. modifier 50 present → 150% of the running amount
  7. modifier 52 present → 50% of the running amount
  8. modifier 54 present → 80% of the running amount
  9. modifier 62 present → 62.5% of the running amount
  10. modifier 78 present → 70% of the running amount
  11. modifier 80 present → 16% of the running amount
  12. modifier 81 present → 16% of the running amount
  13. modifier 82 present → 16% of the running amount
  14. modifier AS present → 14% of the running amount
  15. modifier QY present → 50% of the running amount
  16. modifier QK present → 50% of the running amount
  17. modifier QX present → 50% of the running amount
  18. cap each charge and the account total at 100% of billed charges
BCBS-OR-Profee1 base · 17 adj
BCBS OR
Profee · all facilities · 2023-01-01 → 2999-12-31
Base terms — first match wins
  1. 100% of the Fixed-Fees fee schedule
Adjustments — all apply, in order
  1. Medicare multiple-endoscopy reduction
  2. Medicare multiple-radiology reduction — base codes 4
  3. mid-level provider reduction (by NUCC taxonomy)
  4. modifier 22 present → 135% 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 → 80% of the running amount
  8. modifier 62 present → 62.5% of the running amount
  9. modifier 78 present → 70% of the running amount
  10. modifier 80 present → 16% of the running amount
  11. modifier 81 present → 16% of the running amount
  12. modifier 82 present → 16% of the running amount
  13. modifier AS present → 14% of the running amount
  14. modifier QY present → 50% of the running amount
  15. modifier QK present → 50% of the running amount
  16. modifier QX present → 50% of the running amount
  17. cap each charge and the account total at 100% of billed charges
Charges1 base · 0 adj
Charges
Profee · all facilities · 2022-01-01 → 2999-12-31
Base terms — first match wins
  1. 100% of the Flat-Fees fee schedule
Cigna-Profee1 base · 18 adj
Cigna
Profee · all facilities · 2022-01-01 → 2999-12-31
Base terms — first match wins
  1. 100% of the Fixed-Fees fee schedule
Adjustments — all apply, in order
  1. Medicare multiple-procedure reduction — base codes 2; pays 100/50% — when Modifier MV is absent
  2. Medicare multiple-endoscopy reduction
  3. Medicare multiple-radiology reduction — base codes 4
  4. mid-level provider reduction (by NUCC taxonomy)
  5. modifier 22 present → 135% of the running amount
  6. modifier 50 present → 150% of the running amount
  7. modifier 52 present → 50% of the running amount
  8. modifier 54 present → 80% of the running amount
  9. modifier 62 present → 62.5% of the running amount
  10. modifier 78 present → 70% of the running amount
  11. modifier 80 present → 16% of the running amount
  12. modifier 81 present → 16% of the running amount
  13. modifier 82 present → 16% of the running amount
  14. modifier AS present → 14% of the running amount
  15. modifier QY present → 50% of the running amount
  16. modifier QK present → 50% of the running amount
  17. modifier QX present → 50% of the running amount
  18. cap each charge and the account total at 100% of billed charges
Medicare4 base · 18 adj
Medicare
Profee · all facilities · 2022-01-01 → 2999-12-31
Base terms — first match wins
  1. 100% of Medicare lab
  2. 100% of Medicare drug
  3. 100% of Medicare DME
  4. 100% of Medicare RVU
Adjustments — all apply, in order
  1. Medicare multiple-procedure reduction — base codes 2; pays 100/50%
  2. Medicare multiple-endoscopy reduction
  3. Medicare multiple-radiology reduction
  4. mid-level provider reduction (by NUCC taxonomy)
  5. modifier 22 present → 135% of the running amount
  6. modifier 50 present → 150% of the running amount
  7. modifier 52 present → 50% of the running amount
  8. modifier 54 present → 80% of the running amount
  9. modifier 62 present → 62.5% of the running amount
  10. modifier 78 present → 70% of the running amount
  11. modifier 80 present → 16% of the running amount
  12. modifier 81 present → 16% of the running amount
  13. modifier 82 present → 16% of the running amount
  14. modifier AS present → 14% of the running amount
  15. modifier QY present → 50% of the running amount
  16. modifier QK present → 50% of the running amount
  17. modifier QX present → 50% of the running amount
  18. cap each charge and the account total at 100% of billed charges
Moda-Medicare6 base · 18 adj
Moda Medicare
Profee · all facilities · 2022-01-01 → 2999-12-31
Base terms — first match wins
  1. 102% of Medicare lab
  2. 102% of Medicare drug
  3. 102% of Medicare DME
  4. 102% of Medicare RVU
  5. 102% of Medicare anesthesia
  6. 50% of billed charges
Adjustments — all apply, in order
  1. Medicare multiple-procedure reduction — base codes 2; pays 100/50%
  2. Medicare multiple-endoscopy reduction
  3. Medicare multiple-radiology reduction — base codes 4
  4. mid-level provider reduction (by NUCC taxonomy)
  5. modifier 22 present → 135% of the running amount
  6. modifier 50 present → 150% of the running amount
  7. modifier 52 present → 50% of the running amount
  8. modifier 54 present → 80% of the running amount
  9. modifier 62 present → 62.5% of the running amount
  10. modifier 78 present → 70% of the running amount
  11. modifier 80 present → 16% of the running amount
  12. modifier 81 present → 16% of the running amount
  13. modifier 82 present → 16% of the running amount
  14. modifier AS present → 14% of the running amount
  15. modifier QY present → 50% of the running amount
  16. modifier QK present → 50% of the running amount
  17. modifier QX present → 50% of the running amount
  18. cap each charge and the account total at 50% of billed charges
Moda-Profee6 base · 4 adj
Moda
Profee · all facilities · 2022-01-01 → 2999-12-31
Base terms — first match wins
  1. 110% of Medicare lab (rates as of 2018-01-01) ⚠︎ named “100% of 2018 Medicare Lab” but configured at 110%
  2. 100% of Medicare drug ⚠︎ named “106% Medicare ASP Drug” but configured at 100%
  3. 100% of Medicare DME (rates as of 2010-01-01)
  4. 100% of Medicare RVU (rates as of 2010-01-01)
  5. 100% of Medicare anesthesia (rates as of 2010-01-01)
  6. 70% of billed charges
Adjustments — all apply, in order
  1. mid-level provider reduction (by NUCC taxonomy)
  2. Medicare multiple-procedure reduction — base codes 2; pays 100/50%
  3. Medicare bilateral-surgery adjustment
  4. cap each charge and the account total at 80% of billed charges
PacificSource-Medicare6 base · 18 adj
PacificSource Medicare
Profee · all facilities · 2022-01-01 → 2999-12-31
Base terms — first match wins
  1. 100% of Medicare lab
  2. 100% of Medicare drug
  3. 100% of Medicare DME
  4. 115% of Medicare RVU
  5. 110% of Medicare anesthesia
  6. 40% of billed charges
Adjustments — all apply, in order
  1. Medicare multiple-procedure reduction — base codes 2; pays 100/50%
  2. Medicare multiple-endoscopy reduction
  3. Medicare multiple-radiology reduction — base codes 4
  4. mid-level provider reduction (by NUCC taxonomy)
  5. modifier 22 present → 135% of the running amount
  6. modifier 50 present → 150% of the running amount
  7. modifier 52 present → 50% of the running amount
  8. modifier 54 present → 80% of the running amount
  9. modifier 62 present → 62.5% of the running amount
  10. modifier 78 present → 70% of the running amount
  11. modifier 80 present → 16% of the running amount
  12. modifier 81 present → 16% of the running amount
  13. modifier 82 present → 16% of the running amount
  14. modifier AS present → 14% of the running amount
  15. modifier QY present → 50% of the running amount
  16. modifier QK present → 50% of the running amount
  17. modifier QX present → 50% of the running amount
  18. cap each charge and the account total at 100% of billed charges
PacificSource-Profee5 base · 1 adj
PacificSource
Profee · all facilities · 2022-01-01 → 2999-12-31
Base terms — first match wins
  1. 110% of Medicare lab (OR, rates as of 2018-01-01)
  2. 100% of Medicare drug ⚠︎ named “106% CMS ASP Drug” but configured at 100%
  3. 100% of Medicare DME (rates as of 2010-01-01)
  4. 100% of Medicare RVU (rates as of 2020-07-01)
  5. 100% of Medicare anesthesia
Adjustments — all apply, in order
  1. cap each charge and the account total at 80% of billed charges
Providence6 base · 1 adj
Providence
Profee · all facilities · 2022-01-01 → 2999-12-31
Base terms — first match wins
  1. 100% of Medicare RVU (rates as of 2018-01-01)
  2. 100% of Medicare anesthesia
  3. 110% of Medicare lab (rates as of 2018-01-01)
  4. 125% of Medicare drug
  5. 100% of Medicare DME (rates as of 2018-01-01)
  6. 75% of billed charges
Adjustments — all apply, in order
  1. cap each charge and the account total at 100% of billed charges
Providence-Medicare6 base · 0 adj
Providence Medicare
Profee · all facilities · 2022-01-01 → 2999-12-31
Base terms — first match wins
  1. 105% of Medicare RVU
  2. 100% of Medicare lab
  3. 100% of Medicare drug
  4. 100% of Medicare DME
  5. 100% of Medicare anesthesia
  6. 60% of billed charges
RGA-Profee1 base · 17 adj
Regence Group Adminstrators
Profee · all facilities · 2023-01-01 → 2999-12-31
Base terms — first match wins
  1. 100% of the Fixed-Fees fee schedule
Adjustments — all apply, in order
  1. Medicare multiple-endoscopy reduction
  2. Medicare multiple-radiology reduction — base codes 4
  3. mid-level provider reduction (by NUCC taxonomy)
  4. modifier 22 present → 135% 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 → 80% of the running amount
  8. modifier 62 present → 62.5% of the running amount
  9. modifier 78 present → 70% of the running amount
  10. modifier 80 present → 16% of the running amount
  11. modifier 81 present → 16% of the running amount
  12. modifier 82 present → 16% of the running amount
  13. modifier AS present → 14% of the running amount
  14. modifier QY present → 50% of the running amount
  15. modifier QK present → 50% of the running amount
  16. modifier QX present → 50% of the running amount
  17. cap each charge and the account total at 100% of billed charges
UnitedHealthcare-Profee1 base · 1 adj
United Healthcare
Profee · all facilities · 2022-01-01 → 2999-12-31
Base terms — first match wins
  1. 100% of the Fixed-Fees fee schedule
Adjustments — all apply, in order
  1. cap each charge and the account total at 100% of billed charges