Customer detail

OrthoAlliance

91
live contracts
17
cannot fire
26
calc types
8
SQL bodies
2
of those blocked
8
map conflicts

Methodology mix

ModifierAdjustment1,191
PercentOfFees211
FlatFee107
LesserOfAdjustment97
MedicareMultipleProcedureAdjustment92
MedicareMultipleEndoscopyAdjustment79
FlatPercentOfCharges74
MedicareMultipleTherapyAdjustment72
ChargeLevelSqlAdjustment55
FlatPercentageAdjustment54
CaseRate42
MidLevelProviderAdjustment42
MedicareRVU31
MultipleProcedureAdjustment27
MedicareDrug27
CalculationBuilder19
MedicareASC18
MedicareDME17
MedicareLab15
MedicareAnesthesia9
MultipleSurgeryAdjustment5
ExcludedChargeAdjustment4
MedicareMultipleRadiologyAdjustment4
SqlExpression3
MedicareMultipleOphthalmologyAdjustment2
BCBSMultipleTherapyAdjustment1

Contracts

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

Aetna-Beacon-ASC-20252 base · 17 adj
Aetna
Facility · Beacon ASC · 2025-11-01 → 2026-10-31
Base terms — first match wins
  1. 160% of Medicare ASC
  2. 30% of billed charges
Adjustments — all apply, in order
  1. Medicare multiple-procedure reduction — base codes 2; pays 100/50%
  2. Medicare multiple-therapy reduction (MPPR) — base codes 5; pays 100/50%
  3. zero out charges excluded by the Excluded-RevCode schedule
  4. modifier 22 present → 120% 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. modifier 62 present → 63% 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 25 present → 50% of the running amount
  15. modifier 53 present → 50% of the running amount
  16. modifier 55 present → 20% of the running amount
  17. cap each charge and the account total at 100% of billed charges
Aetna-Beacon-ASC-20262 base · 17 adj
Aetna
Facility · Beacon ASC · 2026-11-01 → 2027-10-31
Base terms — first match wins
  1. 163% of Medicare ASC
  2. 30% of billed charges
Adjustments — all apply, in order
  1. Medicare multiple-procedure reduction — base codes 2; pays 100/50%
  2. Medicare multiple-therapy reduction (MPPR) — base codes 5; pays 100/50%
  3. zero out charges excluded by the Excluded-RevCode schedule
  4. modifier 22 present → 120% 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. modifier 62 present → 63% 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 25 present → 50% of the running amount
  15. modifier 53 present → 50% of the running amount
  16. modifier 55 present → 20% of the running amount
  17. cap each charge and the account total at 100% of billed charges
Aetna-Beacon-ASC-20272 base · 17 adj
Aetna
Facility · Beacon ASC · 2027-11-01 → 2999-12-31
Base terms — first match wins
  1. 166% of Medicare ASC
  2. 30% of billed charges
Adjustments — all apply, in order
  1. Medicare multiple-procedure reduction — base codes 2; pays 100/50%
  2. Medicare multiple-therapy reduction (MPPR) — base codes 5; pays 100/50%
  3. zero out charges excluded by the Excluded-RevCode schedule
  4. modifier 22 present → 120% 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. modifier 62 present → 63% 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 25 present → 50% of the running amount
  15. modifier 53 present → 50% of the running amount
  16. modifier 55 present → 20% of the running amount
  17. cap each charge and the account total at 100% of billed charges
Aetna-Facility --LookInto4 base · 17 adj
Aetna
Facility · 150 named facilities · 2022-08-01 → 2025-10-31
Aetna
Facility · 288 named facilities · 2022-08-01 → 2999-12-31
Aetna
Facility · 4 named facilities · 2022-08-01 → 2024-06-30
Base terms — first match wins
  1. 100% of the Fixed-Fees-Carveout fee schedule
  2. custom SQL — For revenue codes 274 or 278 (implant/DME-type revenue codes) where the already-computed allowed amount is at least $800, replaces it with 50% of billed charges plus a flat $800 add-on.
  3. 0% of the Excluded-ProcCode fee schedule
  4. 100% of the ASC-Grouper fee schedule
Adjustments — all apply, in order
  1. Medicare multiple-procedure reduction — base codes 2; pays 100/50%
  2. Medicare multiple-therapy reduction (MPPR) — base codes 5; pays 100/50%
  3. zero out charges excluded by the Excluded-RevCode schedule
  4. rescale to 85% of the running amount — when Mid-Level-Providers Mid-Level is present
  5. modifier 22 present → 120% 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. modifier 62 present → 63% 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 25 present → 50% of the running amount
  16. modifier 53 present → 50% of the running amount
  17. modifier 55 present → 20% of the running amount
Aetna-OH-Profee2 base · 16 adj
Aetna
Profee · Beacon ASC, Non-OA Ohio, OA JV, OA Ohio · 2022-01-01 → 2999-12-31
Base terms — first match wins
  1. 100% of Medicare drug
  2. 100% of the Profee-Fees fee schedule
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. BCBS multiple-therapy reduction — base codes 5; pays 100/50%
  5. mid-level provider reduction (by NUCC taxonomy)
  6. modifier 22 present → 120% 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 → 14% of the running amount
  16. cap each charge and the account total at 100% of billed charges
Ambetter-OH-Facility2 base · 16 adj
Ambetter
Facility · Beacon ASC · 2025-10-01 → 2999-12-31
Base terms — first match wins
  1. 100% of the Ambetter-ASC-Fees fee schedule
  2. 40% of billed charges
Adjustments — all apply, in order
  1. Medicare multiple-procedure reduction — base codes 2; pays 100/50%
  2. Medicare multiple-therapy reduction (MPPR) — base codes 5; pays 100/50%
  3. custom SQL — Caps a charge's allowed amount when its billed units exceed a per-procedure maximum-allowed-units limit (a therapy/multiple-unit cap): if the code has a configured max-units value and billed Units exceed it, the allowed amount is scaled down proportionally (Allowed * maxUnits/units); otherwise Allowed passes through unchanged. — when CMS_Therapy_Codes True is present
  4. Medicare multiple-endoscopy reduction
  5. mid-level provider reduction (by NUCC taxonomy)
  6. modifier 22 present → 120% 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
Anthem Medicare Advantage7 base · 15 adj
Anthem Medicare Advantage
Profee · Non-OA Ohio, OA JV, OA Ohio · 2022-01-01 → 2999-12-31
Base terms — first match wins
  1. 100% of Medicare lab
  2. 100% of Medicare drug
  3. 100% of Medicare DME
  4. 100% of Medicare RVU
  5. flat $0 — when ProcedureCode 20930 is present
  6. flat $0 — when ProcedureCode 20936 is present
  7. flat $0 — when ProcedureCode 17999 is present
Adjustments — all apply, in order
  1. Medicare multiple-procedure reduction — base codes 2; pays 100/50%
  2. Medicare multiple-therapy reduction (MPPR) — base codes 5; pays 100/50%
  3. Medicare multiple-endoscopy reduction
  4. rescale to 85% of the running amount — when Mid-Level-Providers Mid-Level is present
  5. modifier 22 present → 120% 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
Anthem-Facility --LookInto3 base · 19 adj
Anthem
Facility · Beacon ASC, Non-OA Ohio, OA JV, OA Ohio · 2023-01-01 → 2025-05-31
Anthem BCBS
Facility · Beacon ASC · 2023-01-01 → 2025-05-31
Anthem Health Care Exchange
Facility · Beacon ASC · 2023-01-01 → 2025-05-31
Base terms — first match wins
  1. 100% of the Fixed-Fees fee schedule
  2. 100% of the ASC-Grouper fee schedule
  3. 50% of billed charges
Adjustments — all apply, in order
  1. multiple-procedure reduction (contract rules) — base codes 2; pays 100/35%
  2. multiple-procedure reduction (contract rules) — base codes 2; pays 100/30%
  3. multiple-procedure reduction (contract rules) — base codes 2; pays 100/25%
  4. mid-level provider reduction (by NUCC taxonomy)
  5. Medicare multiple-procedure reduction — base codes 2, 3; pays 100/50/25/0%
  6. modifier 22 present → 120% 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 → 70% of the running amount
  10. modifier 62 present → 63% 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 → 14% of the running amount
  16. modifier 25 present → 50% of the running amount
  17. modifier 53 present → 50% of the running amount
  18. modifier 55 present → 20% of the running amount
  19. cap each charge and the account total at 100% of billed charges
Anthem-Ohio-Profees-2024-to-2026 (POS Split)25 base · 17 adj
Anthem
Profee · Non-OA Ohio, OA Ohio, Other · 2024-04-01 → 2099-12-31
Anthem BCBS
Profee · Non-OA Ohio, OA Ohio, Other · 2024-04-01 → 2099-12-31
Anthem Health Care Exchange
Profee · Non-OA Ohio, OA Ohio, Other · 2024-04-01 → 2099-12-31
Base terms — first match wins
  1. 100% of the Anthem-Therapist-Facility-Profee fee schedule — when ProviderType Respiratory Therapist, Certified is present; PlaceOfService 11 is absent
  2. 100% of the Anthem-Therapist-Facility-Profee fee schedule — when ProviderType Physical Therapist is present; PlaceOfService 11 is absent
  3. 100% of the Anthem-Therapist-Clinic-Profee fee schedule — when ProviderType Respiratory Therapist, Certified is present
  4. 100% of the Anthem-Therapist-Clinic-Profee fee schedule — when ProviderType Physical Therapist is present
  5. 100% of the Anthem-Podiatrist-Profee-Clinic fee schedule — when ProviderType Podiatrist is present; PlaceOfService 24 is absent
  6. 100% of the Anthem-Podiatrist-Profee-ASC fee schedule — when ProviderType Podiatrist is present; PlaceOfService 24 is present
  7. 100% of the Anthem-Fixed-Fees-Podiatrist-Clinic fee schedule — when ProviderType Podiatrist is present; PlaceOfService 24 is absent
  8. 100% of the Anthem-Fixed-Fees-Podiatrist-ASC fee schedule — when ProviderType Podiatrist is present; PlaceOfService 24 is present
  9. 100% of the Anthem-ASC-Profee-Fees fee schedule — when ProviderType Podiatrist is absent; PlaceOfService 24 is present
  10. 100% of the Anthem-Clinic-Profee-Fees fee schedule — when ProviderType Podiatrist is absent; PlaceOfService 19 is present
  11. 100% of the Anthem-Clinic-Profee-Fees fee schedule — when ProviderType Podiatrist is absent; PlaceOfService 21 is present
  12. 100% of the Anthem-Clinic-Profee-Fees fee schedule — when ProviderType Podiatrist is absent; PlaceOfService 22 is present
  13. 100% of the Anthem-Clinic-Profee-Fees fee schedule — when ProviderType Podiatrist is absent; PlaceOfService 23 is present
  14. 100% of the Anthem-Clinic-Profee-Fees fee schedule — when ProviderType Podiatrist is absent; PlaceOfService 11 is present
  15. 100% of the Anthem-Clinic-Profee-Fees fee schedule — when ProviderType Podiatrist is absent; PlaceOfService 12 is present
  16. 100% of the Anthem-Clinic-Profee-Fees fee schedule — when ProviderType Podiatrist is absent
  17. 100% of the Fixed-Fees-DME fee schedule — when ProviderType Podiatrist is absent; PlaceOfService 11 is present
  18. 100% of the Fixed-Fees-DME fee schedule — when ProviderType Podiatrist is absent; PlaceOfService 12 is present
  19. 100% of the Fixed-Fees-DME-Facility fee schedule — when ProviderType Podiatrist is absent
  20. 100% of Medicare drug
  21. 113.61% of Medicare DME ⚠︎ named “111.2% Medicare Lab Fallback” but configured at 113.61%
  22. 113.61% of Medicare lab ⚠︎ named “111.2% Medicare DME Fallback” but configured at 113.61%
  23. 113.61% of Medicare RVU ⚠︎ named “111.2% Medicare RVU Fallback” but configured at 113.61%
  24. flat $0 — when UnlistedProceduresCPT True is present
  25. flat $0 — when CMS_Status_Code Noncovered is present
Adjustments — all apply, in order
  1. mid-level provider reduction (by NUCC taxonomy)
  2. Medicare multiple-procedure reduction — base codes 2, 3; pays 100/50/25/0%
  3. Medicare multiple-endoscopy reduction
  4. modifier 22 present → 120% 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. modifier 62 present → 63% 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 25 present → 50% of the running amount
  15. modifier 53 present → 50% of the running amount
  16. modifier 55 present → 20% of the running amount
  17. cap each charge and the account total at 100% of billed charges
Anthem-Ohio-Profees-2024-to-2026 (POS Split)25 base · 17 adj
Anthem
Profee · 6 named facilities · 2024-04-01 → 2099-12-31
Anthem BCBS
Profee · 6 named facilities · 2024-04-01 → 2099-12-31
Anthem Health Care Exchange
Profee · 6 named facilities · 2024-04-01 → 2099-12-31
Base terms — first match wins
  1. 100% of the Anthem-Therapist-Facility-Profee fee schedule — when ProviderType Respiratory Therapist, Certified is present; PlaceOfService 11 is absent
  2. 100% of the Anthem-Therapist-Facility-Profee fee schedule — when ProviderType Physical Therapist is present; PlaceOfService 11 is absent
  3. 100% of the Anthem-Therapist-Clinic-Profee fee schedule — when ProviderType Respiratory Therapist, Certified is present
  4. 100% of the Anthem-Therapist-Clinic-Profee fee schedule — when ProviderType Physical Therapist is present
  5. 100% of the Anthem-Podiatrist-Profee-Clinic fee schedule — when ProviderType Podiatrist is present; PlaceOfService 24 is absent
  6. 100% of the Anthem-Podiatrist-Profee-ASC fee schedule — when ProviderType Podiatrist is present; PlaceOfService 24 is present
  7. 100% of the Anthem-Fixed-Fees-Podiatrist-Clinic fee schedule — when ProviderType Podiatrist is present; PlaceOfService 24 is absent
  8. 100% of the Anthem-Fixed-Fees-Podiatrist-ASC fee schedule — when ProviderType Podiatrist is present; PlaceOfService 24 is present
  9. 100% of the Anthem-ASC-Profee-Fees fee schedule — when ProviderType Podiatrist is absent; PlaceOfService 24 is present
  10. 100% of the Anthem-Clinic-Profee-Fees fee schedule — when ProviderType Podiatrist is absent; PlaceOfService 19 is present
  11. 100% of the Anthem-Clinic-Profee-Fees fee schedule — when ProviderType Podiatrist is absent; PlaceOfService 21 is present
  12. 100% of the Anthem-Clinic-Profee-Fees fee schedule — when ProviderType Podiatrist is absent; PlaceOfService 22 is present
  13. 100% of the Anthem-Clinic-Profee-Fees fee schedule — when ProviderType Podiatrist is absent; PlaceOfService 23 is present
  14. 100% of the Anthem-Clinic-Profee-Fees fee schedule — when ProviderType Podiatrist is absent; PlaceOfService 11 is present
  15. 100% of the Anthem-Clinic-Profee-Fees fee schedule — when ProviderType Podiatrist is absent; PlaceOfService 12 is present
  16. 100% of the Anthem-Clinic-Profee-Fees fee schedule — when ProviderType Podiatrist is absent
  17. 100% of the Fixed-Fees-DME fee schedule — when ProviderType Podiatrist is absent; PlaceOfService 11 is present
  18. 100% of the Fixed-Fees-DME fee schedule — when ProviderType Podiatrist is absent; PlaceOfService 12 is present
  19. 100% of the Fixed-Fees-DME-Facility fee schedule — when ProviderType Podiatrist is absent
  20. 100% of Medicare drug
  21. 113.61% of Medicare DME ⚠︎ named “111.2% Medicare Lab Fallback” but configured at 113.61%
  22. 113.61% of Medicare lab ⚠︎ named “111.2% Medicare DME Fallback” but configured at 113.61%
  23. 113.61% of Medicare RVU ⚠︎ named “111.2% Medicare RVU Fallback” but configured at 113.61%
  24. flat $0 — when UnlistedProceduresCPT True is present
  25. flat $0 — when CMS_Status_Code Noncovered is present
Adjustments — all apply, in order
  1. mid-level provider reduction (by NUCC taxonomy)
  2. Medicare multiple-procedure reduction — base codes 2, 3; pays 100/50/25/0%
  3. Medicare multiple-endoscopy reduction
  4. modifier 22 present → 120% 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. modifier 62 present → 63% 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 25 present → 50% of the running amount
  15. modifier 53 present → 50% of the running amount
  16. modifier 55 present → 20% of the running amount
  17. cap each charge and the account total at 100% of billed charges
Anthem-Profee-ASC10 base · 20 adj
Anthem
Profee · CIO ASC, Non-OA Indiana, OA Indiana, ASC, Hospital · 2024-04-01 → 2999-12-31
Base terms — first match wins
  1. 100% of the Fixed-Fees-Podiatrist-Hospital fee schedule — when ProviderType Podiatrist is present
  2. 100% of the Carveout-Fees-ASC fee schedule
  3. 100% of the Fixed-Fees-PT fee schedule — when ProviderType Physical Medicine & Rehabilitation is present
  4. 100% of the Fixed-Fees-PT fee schedule — when ProviderType Physical Therapist is present
  5. 100% of the Fixed-Fees-DME fee schedule
  6. 100% of the Fixed-Fees-Drug fee schedule
  7. 108% of Medicare RVU
  8. flat $0 — when ProcedureCode 20930 is present
  9. flat $0 — when ProcedureCode 20936 is present
  10. flat $0 — when ProcedureCode 17999 is present
Adjustments — all apply, in order
  1. multiple-procedure reduction (contract rules) — base codes 2; pays 100/35%
  2. multiple-procedure reduction (contract rules) — base codes 2; pays 100/30%
  3. multiple-procedure reduction (contract rules) — base codes 2; pays 100/25%
  4. rescale to 85% of the running amount — when Mid-Level-Providers Mid-Level is present
  5. Medicare multiple-procedure reduction — base codes 2; pays 100/50%
  6. Medicare multiple-endoscopy reduction
  7. modifier 22 present → 120% 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 → 70% of the running amount
  11. modifier 62 present → 63% 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 → 14% of the running amount
  17. modifier 25 present → 50% of the running amount
  18. modifier 53 present → 50% of the running amount
  19. modifier 55 present → 20% of the running amount
  20. cap each charge and the account total at 100% of billed charges
Anthem-Profee-ASC-Ohio-Pre-2024-Medicare-Drug11 base · 20 adj
Anthem
Profee · Non-OA Ohio, OA JV, OA Ohio, ASC, Hospital, SNF · 2022-01-01 → 2024-03-31
Base terms — first match wins
  1. 100% of Medicare drug
  2. 100% of the Fixed-Fees-Podiatrist-Hospital fee schedule — when ProviderType Podiatrist is present
  3. 100% of the Carveout-Fees-ASC fee schedule
  4. 100% of the Fixed-Fees-PT fee schedule — when ProviderType Physical Medicine & Rehabilitation is present
  5. 100% of the Fixed-Fees-PT fee schedule — when ProviderType Physical Therapist is present
  6. 100% of the Fixed-Fees-DME fee schedule
  7. 100% of the Fixed-Fees-Drug fee schedule
  8. 108% of Medicare RVU
  9. flat $0 — when ProcedureCode 20930 is present
  10. flat $0 — when ProcedureCode 20936 is present
  11. flat $0 — when ProcedureCode 17999 is present
Adjustments — all apply, in order
  1. multiple-procedure reduction (contract rules) — base codes 2; pays 100/35%
  2. multiple-procedure reduction (contract rules) — base codes 2; pays 100/30%
  3. multiple-procedure reduction (contract rules) — base codes 2; pays 100/25%
  4. rescale to 85% of the running amount — when Mid-Level-Providers Mid-Level is present
  5. Medicare multiple-procedure reduction — base codes 2; pays 100/50%
  6. Medicare multiple-endoscopy reduction
  7. modifier 22 present → 120% 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 → 70% of the running amount
  11. modifier 62 present → 63% 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 → 14% of the running amount
  17. modifier 25 present → 50% of the running amount
  18. modifier 53 present → 50% of the running amount
  19. modifier 55 present → 20% of the running amount
  20. cap each charge and the account total at 100% of billed charges
Anthem-Profee-Clinic10 base · 17 adj
Anthem
Profee · CIO ASC, Non-OA Indiana, OA Indiana, Clinic · 2024-04-01 → 2999-12-31
Base terms — first match wins
  1. 100% of the Fixed-Fees-Podiatrist-Clinic fee schedule — when ProviderType Podiatrist is present
  2. 100% of the Carveout-Fees fee schedule
  3. 100% of the Fixed-Fees-PT fee schedule — when ProviderType Physical Medicine & Rehabilitation is present
  4. 100% of the Fixed-Fees-PT fee schedule — when ProviderType Physical Therapist is present
  5. 100% of the Fixed-Fees-DME fee schedule
  6. 100% of the Fixed-Fees-Drug fee schedule
  7. 108% of Medicare RVU
  8. flat $0 — when ProcedureCode 20930 is present
  9. flat $0 — when ProcedureCode 20936 is present
  10. flat $0 — when ProcedureCode 17999 is present
Adjustments — all apply, in order
  1. rescale to 85% of the running amount — when Mid-Level-Providers Mid-Level is present
  2. Medicare multiple-procedure reduction — base codes 2; pays 100/50%
  3. Medicare multiple-endoscopy reduction
  4. modifier 22 present → 120% 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. modifier 62 present → 63% 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 25 present → 50% of the running amount
  15. modifier 53 present → 50% of the running amount
  16. modifier 55 present → 20% of the running amount
  17. cap each charge and the account total at 100% of billed charges
Anthem-Profee-Clinic-Ohio-pre-2024-Medicare-Drug11 base · 17 adj
Anthem
Profee · Non-OA Ohio, OA JV, OA Ohio, Clinic · 2022-01-01 → 2024-03-31
Base terms — first match wins
  1. 100% of Medicare drug
  2. 100% of the Fixed-Fees-Podiatrist-Clinic fee schedule — when ProviderType Podiatrist is present
  3. 100% of the Carveout-Fees fee schedule
  4. 100% of the Fixed-Fees-PT fee schedule — when ProviderType Physical Medicine & Rehabilitation is present
  5. 100% of the Fixed-Fees-PT fee schedule — when ProviderType Physical Therapist is present
  6. 100% of the Fixed-Fees-DME fee schedule
  7. 100% of the Fixed-Fees-Drug fee schedule
  8. 108% of Medicare RVU
  9. flat $0 — when ProcedureCode 20930 is present
  10. flat $0 — when ProcedureCode 20936 is present
  11. flat $0 — when ProcedureCode 17999 is present
Adjustments — all apply, in order
  1. rescale to 85% of the running amount — when Mid-Level-Providers Mid-Level is present
  2. Medicare multiple-procedure reduction — base codes 2; pays 100/50%
  3. Medicare multiple-endoscopy reduction
  4. modifier 22 present → 120% 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. modifier 62 present → 63% 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 25 present → 50% of the running amount
  15. modifier 53 present → 50% of the running amount
  16. modifier 55 present → 20% of the running amount
  17. cap each charge and the account total at 100% of billed charges
Beacon-Anthem Facility Fees (6.1.2025)8 base · 19 adj
Anthem
Facility · Beacon ASC, Non-OA Ohio, OA JV, OA Ohio · 2025-06-01 → 2999-12-31
Anthem BCBS
Facility · Beacon ASC, Non-OA Ohio, OA JV, OA Ohio · 2025-06-01 → 2999-12-31
Anthem Health Care Exchange
Facility · Beacon ASC, Non-OA Ohio, OA JV, OA Ohio · 2025-06-01 → 2999-12-31
Base terms — first match wins
  1. 100% of billed charges — when CodeRange in J7330–J7330
  2. 174.7% of Medicare ASC — when ProcedureCode 27130 is present
  3. 174.7% of Medicare ASC — when ProcedureCode 27447 is present
  4. 115.7% of Medicare ASC
  5. 115.7% of the an unmapped schedule fee schedule
  6. 115.7% of the an unmapped schedule fee schedule
  7. 115.7% of the an unmapped schedule fee schedule
  8. 50% of billed charges
Adjustments — all apply, in order
  1. multiple-procedure reduction (contract rules) — base codes 2; pays 100/35%
  2. multiple-procedure reduction (contract rules) — base codes 2; pays 100/30%
  3. multiple-procedure reduction (contract rules) — base codes 2; pays 100/25%
  4. mid-level provider reduction (by NUCC taxonomy)
  5. Medicare multiple-procedure reduction — base codes 2, 3; pays 100/50/25/0%
  6. modifier 22 present → 120% 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 → 70% of the running amount
  10. modifier 62 present → 63% 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 → 14% of the running amount
  16. modifier 25 present → 50% of the running amount
  17. modifier 53 present → 50% of the running amount
  18. modifier 55 present → 20% of the running amount
  19. cap each charge and the account total at 100% of billed charges
Beacon-United-Healthcare-ASC-202613 base · 19 adj
United Healthcare
Facility · Beacon ASC · 2026-03-01 → 2027-02-28
Base terms — first match wins
  1. 100% of billed charges — when ProcedureCode C1713 is present; RevenueCode 274 is present
  2. 100% of billed charges — when ProcedureCode C1713 is present; RevenueCode 275 is present
  3. 100% of billed charges — when ProcedureCode C1713 is present; RevenueCode 276 is present
  4. 100% of billed charges — when ProcedureCode C1713 is present; RevenueCode 278 is present
  5. case rate from Fixed-Fees-Case-Rate (All-level codes) — when RevenueCode 360 is present
  6. case rate from Fixed-Fees-Case-Rate (All-level codes) — when RevenueCode 361 is present
  7. case rate from Fixed-Fees-Case-Rate (All-level codes) — when RevenueCode 369 is present
  8. case rate from Fixed-Fees-Case-Rate (All-level codes) — when RevenueCode 481 is present
  9. case rate from Fixed-Fees-Case-Rate (All-level codes) — when RevenueCode 490 is present
  10. case rate from Fixed-Fees-Case-Rate (All-level codes) — when RevenueCode 499 is present
  11. case rate from Fixed-Fees-Case-Rate (All-level codes) — when RevenueCode 750 is present
  12. case rate from Fixed-Fees-Case-Rate (All-level codes) — when RevenueCode 790 is present
  13. 100% of the BeaconASC-UnitedHealthcare-Facility fee schedule
Adjustments — all apply, in order
  1. multiple-surgery reduction (contract rules) — pays 100/50/25/0%
  2. custom SQL — Caps a charge's allowed amount when its billed units exceed a per-procedure maximum-allowed-units limit (a therapy/multiple-unit cap): if the code has a configured max-units value and billed Units exceed it, the allowed amount is scaled down proportionally (Allowed * maxUnits/units); otherwise Allowed passes through unchanged. — when CMS_Therapy_Codes True is present
  3. rescale to 85% of the running amount — when Mid-Level-Providers Mid-Level is present
  4. Medicare multiple-endoscopy reduction
  5. modifier 22 present → 120% 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. modifier 62 present → 63% 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 25 present → 50% of the running amount
  16. modifier 53 present → 50% of the running amount
  17. modifier 55 present → 20% of the running amount
  18. cap each charge and the account total at 100% of billed charges
  19. custom SQL — Caps the allowed amount at $7,000 for HCPCS C1713 (a device/implant pass-through code), otherwise leaves the already-computed Allowed amount unchanged. — when ProcedureCode C1713 is present
Beacon-United-Healthcare-ASC-202713 base · 19 adj
United Healthcare
Facility · Beacon ASC · 2027-03-01 → 2028-02-28
Base terms — first match wins
  1. 100% of billed charges — when ProcedureCode C1713 is present; RevenueCode 274 is present
  2. 100% of billed charges — when ProcedureCode C1713 is present; RevenueCode 275 is present
  3. 100% of billed charges — when ProcedureCode C1713 is present; RevenueCode 276 is present
  4. 100% of billed charges — when ProcedureCode C1713 is present; RevenueCode 278 is present
  5. case rate from Fixed-Fees-Case-Rate (All-level codes) — when RevenueCode 360 is present
  6. case rate from Fixed-Fees-Case-Rate (All-level codes) — when RevenueCode 361 is present
  7. case rate from Fixed-Fees-Case-Rate (All-level codes) — when RevenueCode 369 is present
  8. case rate from Fixed-Fees-Case-Rate (All-level codes) — when RevenueCode 481 is present
  9. case rate from Fixed-Fees-Case-Rate (All-level codes) — when RevenueCode 490 is present
  10. case rate from Fixed-Fees-Case-Rate (All-level codes) — when RevenueCode 499 is present
  11. case rate from Fixed-Fees-Case-Rate (All-level codes) — when RevenueCode 750 is present
  12. case rate from Fixed-Fees-Case-Rate (All-level codes) — when RevenueCode 790 is present
  13. 104% of the BeaconASC-UnitedHealthcare-Facility fee schedule
Adjustments — all apply, in order
  1. multiple-surgery reduction (contract rules) — pays 100/50/25/0%
  2. custom SQL — Caps a charge's allowed amount when its billed units exceed a per-procedure maximum-allowed-units limit (a therapy/multiple-unit cap): if the code has a configured max-units value and billed Units exceed it, the allowed amount is scaled down proportionally (Allowed * maxUnits/units); otherwise Allowed passes through unchanged. — when CMS_Therapy_Codes True is present
  3. rescale to 85% of the running amount — when Mid-Level-Providers Mid-Level is present
  4. Medicare multiple-endoscopy reduction
  5. modifier 22 present → 120% 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. modifier 62 present → 63% 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 25 present → 50% of the running amount
  16. modifier 53 present → 50% of the running amount
  17. modifier 55 present → 20% of the running amount
  18. cap each charge and the account total at 100% of billed charges
  19. custom SQL — Caps the allowed amount at $7,000 for HCPCS C1713 (a device/implant pass-through code), otherwise leaves the already-computed Allowed amount unchanged. — when ProcedureCode C1713 is present
Beacon-United-Healthcare-ASC-202813 base · 19 adj
United Healthcare
Facility · Beacon ASC · 2028-03-01 → 2099-12-31
Base terms — first match wins
  1. 100% of billed charges — when ProcedureCode C1713 is present; RevenueCode 274 is present
  2. 100% of billed charges — when ProcedureCode C1713 is present; RevenueCode 275 is present
  3. 100% of billed charges — when ProcedureCode C1713 is present; RevenueCode 276 is present
  4. 100% of billed charges — when ProcedureCode C1713 is present; RevenueCode 278 is present
  5. case rate from Fixed-Fees-Case-Rate (All-level codes) — when RevenueCode 360 is present
  6. case rate from Fixed-Fees-Case-Rate (All-level codes) — when RevenueCode 361 is present
  7. case rate from Fixed-Fees-Case-Rate (All-level codes) — when RevenueCode 369 is present
  8. case rate from Fixed-Fees-Case-Rate (All-level codes) — when RevenueCode 481 is present
  9. case rate from Fixed-Fees-Case-Rate (All-level codes) — when RevenueCode 490 is present
  10. case rate from Fixed-Fees-Case-Rate (All-level codes) — when RevenueCode 499 is present
  11. case rate from Fixed-Fees-Case-Rate (All-level codes) — when RevenueCode 750 is present
  12. case rate from Fixed-Fees-Case-Rate (All-level codes) — when RevenueCode 790 is present
  13. 108% of the BeaconASC-UnitedHealthcare-Facility fee schedule
Adjustments — all apply, in order
  1. multiple-surgery reduction (contract rules) — pays 100/50/25/0%
  2. custom SQL — Caps a charge's allowed amount when its billed units exceed a per-procedure maximum-allowed-units limit (a therapy/multiple-unit cap): if the code has a configured max-units value and billed Units exceed it, the allowed amount is scaled down proportionally (Allowed * maxUnits/units); otherwise Allowed passes through unchanged. — when CMS_Therapy_Codes True is present
  3. rescale to 85% of the running amount — when Mid-Level-Providers Mid-Level is present
  4. Medicare multiple-endoscopy reduction
  5. modifier 22 present → 120% 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. modifier 62 present → 63% 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 25 present → 50% of the running amount
  16. modifier 53 present → 50% of the running amount
  17. modifier 55 present → 20% of the running amount
  18. cap each charge and the account total at 100% of billed charges
  19. custom SQL — Caps the allowed amount at $7,000 for HCPCS C1713 (a device/implant pass-through code), otherwise leaves the already-computed Allowed amount unchanged. — when ProcedureCode C1713 is present
CIO Fishers ASC - Aetna (7.1.2024)2 base · 16 adj
Aetna
Facility · 2 named facilities · 2024-07-01 → 2999-12-31
Base terms — first match wins
  1. 100% of the Facility-Fees fee schedule
  2. flat $500
Adjustments — all apply, in order
  1. Medicare multiple-procedure reduction — base codes 2; pays 100/50%
  2. Medicare multiple-therapy reduction (MPPR) — base codes 5; pays 100/50%
  3. custom SQL — Caps a charge's allowed amount when its billed units exceed a per-procedure maximum-allowed-units limit (a therapy/multiple-unit cap): if the code has a configured max-units value and billed Units exceed it, the allowed amount is scaled down proportionally (Allowed * maxUnits/units); otherwise Allowed passes through unchanged. — when CMS_Therapy_Codes True is present
  4. Medicare multiple-endoscopy reduction
  5. mid-level provider reduction (by NUCC taxonomy)
  6. modifier 22 present → 120% 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
CIO Fishers ASC - Anthem (7.1.2024)2 base · 16 adj
Anthem
Facility · 2 named facilities · 2024-07-01 → 2999-12-31
Anthem BCBS
Facility · 2 named facilities · 2024-07-01 → 2999-12-31
Base terms — first match wins
  1. 100% of the Facility-Fees fee schedule
  2. flat $500
Adjustments — all apply, in order
  1. Medicare multiple-procedure reduction — base codes 2; pays 100/50%
  2. Medicare multiple-therapy reduction (MPPR) — base codes 5; pays 100/50%
  3. custom SQL — Caps a charge's allowed amount when its billed units exceed a per-procedure maximum-allowed-units limit (a therapy/multiple-unit cap): if the code has a configured max-units value and billed Units exceed it, the allowed amount is scaled down proportionally (Allowed * maxUnits/units); otherwise Allowed passes through unchanged. — when CMS_Therapy_Codes True is present
  4. Medicare multiple-endoscopy reduction
  5. mid-level provider reduction (by NUCC taxonomy)
  6. modifier 22 present → 120% 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
CIO Fishers ASC - Ascension (7.1.2024)3 base · 16 adj
Ascension
Facility · 2 named facilities · 2024-07-01 → 2999-12-31
Base terms — first match wins
  1. 50% of billed charges — when RevenueCode 278 is present
  2. 100% of the Facility-Fees fee schedule
  3. 53% of billed charges
Adjustments — all apply, in order
  1. Medicare multiple-procedure reduction — base codes 2; pays 100/50%
  2. Medicare multiple-therapy reduction (MPPR) — base codes 5; pays 100/50%
  3. custom SQL — Caps a charge's allowed amount when its billed units exceed a per-procedure maximum-allowed-units limit (a therapy/multiple-unit cap): if the code has a configured max-units value and billed Units exceed it, the allowed amount is scaled down proportionally (Allowed * maxUnits/units); otherwise Allowed passes through unchanged. — when CMS_Therapy_Codes True is present
  4. Medicare multiple-endoscopy reduction
  5. mid-level provider reduction (by NUCC taxonomy)
  6. modifier 22 present → 120% 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
CIO Fishers ASC - CareSource (7.1.2024)2 base · 16 adj
Care Source Exchange
Facility · 1 named facilities · 2024-07-01 → 2999-12-31
Base terms — first match wins
  1. 140% of Medicare ASC
  2. flat $0 — when CMS_Status_Code Noncovered is present
Adjustments — all apply, in order
  1. Medicare multiple-procedure reduction — base codes 2; pays 100/50%
  2. Medicare multiple-therapy reduction (MPPR) — base codes 5; pays 100/50%
  3. custom SQL — Caps a charge's allowed amount when its billed units exceed a per-procedure maximum-allowed-units limit (a therapy/multiple-unit cap): if the code has a configured max-units value and billed Units exceed it, the allowed amount is scaled down proportionally (Allowed * maxUnits/units); otherwise Allowed passes through unchanged. — when CMS_Therapy_Codes True is present
  4. Medicare multiple-endoscopy reduction
  5. mid-level provider reduction (by NUCC taxonomy)
  6. modifier 22 present → 120% 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
CIO Fishers ASC - ClaimDOC (7.1.2024)2 base · 16 adj
Claim DOC
Facility · 2 named facilities · 2024-07-01 → 2999-12-31
Base terms — first match wins
  1. 179% of Medicare ASC
  2. flat $0 — when CMS_Status_Code Noncovered is present
Adjustments — all apply, in order
  1. Medicare multiple-procedure reduction — base codes 2; pays 100/50%
  2. Medicare multiple-therapy reduction (MPPR) — base codes 5; pays 100/50%
  3. custom SQL — Caps a charge's allowed amount when its billed units exceed a per-procedure maximum-allowed-units limit (a therapy/multiple-unit cap): if the code has a configured max-units value and billed Units exceed it, the allowed amount is scaled down proportionally (Allowed * maxUnits/units); otherwise Allowed passes through unchanged. — when CMS_Therapy_Codes True is present
  4. Medicare multiple-endoscopy reduction
  5. mid-level provider reduction (by NUCC taxonomy)
  6. modifier 22 present → 120% 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
CIO Fishers ASC - IU Health (7.1.2024)4 base · 16 adj
IU Senate Health
Facility · 1 named facilities · 2024-07-01 → 2999-12-31
Base terms — first match wins
  1. 105% of billed charges — when RevenueCode 278 is present
  2. 100% of Medicare ASC
  3. 55% of billed charges ⚠︎ named “50% of Billed Charges Fallback” but configured at 55%
  4. flat $0 — when CMS_Status_Code Noncovered is present
Adjustments — all apply, in order
  1. Medicare multiple-procedure reduction — base codes 2; pays 100/50%
  2. Medicare multiple-therapy reduction (MPPR) — base codes 5; pays 100/50%
  3. custom SQL — Caps a charge's allowed amount when its billed units exceed a per-procedure maximum-allowed-units limit (a therapy/multiple-unit cap): if the code has a configured max-units value and billed Units exceed it, the allowed amount is scaled down proportionally (Allowed * maxUnits/units); otherwise Allowed passes through unchanged. — when CMS_Therapy_Codes True is present
  4. Medicare multiple-endoscopy reduction
  5. mid-level provider reduction (by NUCC taxonomy)
  6. modifier 22 present → 120% 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
CIO Fishers ASC - UHC (7.1.2024)1 base · 16 adj
United Healthcare
Facility · 2 named facilities · 2024-07-01 → 2999-12-31
Base terms — first match wins
  1. 100% of the Facility-Fees fee schedule
Adjustments — all apply, in order
  1. Medicare multiple-procedure reduction — base codes 2; pays 100/50%
  2. Medicare multiple-therapy reduction (MPPR) — base codes 5; pays 100/50%
  3. custom SQL — Caps a charge's allowed amount when its billed units exceed a per-procedure maximum-allowed-units limit (a therapy/multiple-unit cap): if the code has a configured max-units value and billed Units exceed it, the allowed amount is scaled down proportionally (Allowed * maxUnits/units); otherwise Allowed passes through unchanged. — when CMS_Therapy_Codes True is present
  4. Medicare multiple-endoscopy reduction
  5. mid-level provider reduction (by NUCC taxonomy)
  6. modifier 22 present → 120% 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
CIO Muncie ASC - Aetna (7.1.2024)2 base · 17 adj
Aetna
Facility · 2 named facilities · 2024-07-01 → 2999-12-31
Base terms — first match wins
  1. 100% of the Facility-Fees fee schedule
  2. 65% of billed charges
Adjustments — all apply, in order
  1. Medicare multiple-procedure reduction — base codes 2; pays 100/50%
  2. Medicare multiple-therapy reduction (MPPR) — base codes 5; pays 100/50%
  3. custom SQL — Caps a charge's allowed amount when its billed units exceed a per-procedure maximum-allowed-units limit (a therapy/multiple-unit cap): if the code has a configured max-units value and billed Units exceed it, the allowed amount is scaled down proportionally (Allowed * maxUnits/units); otherwise Allowed passes through unchanged. — when CMS_Therapy_Codes True is present
  4. Medicare multiple-endoscopy reduction
  5. mid-level provider reduction (by NUCC taxonomy)
  6. modifier 22 present → 120% 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. custom SQL — 5% invoice surcharge applied to already-allowed amounts of $400+ when revenue code 278 (implant/supply-related) is present on the charge. — when RevenueCode 278 is present
  17. cap each charge and the account total at 100% of billed charges
CIO Muncie ASC - Anthem (7.1.2024)2 base · 17 adj
Anthem
Facility · 2 named facilities · 2024-07-01 → 2999-12-31
Anthem BCBS
Facility · 2 named facilities · 2024-07-01 → 2999-12-31
Base terms — first match wins
  1. 100% of the Facility-Fees fee schedule
  2. 65% of billed charges
Adjustments — all apply, in order
  1. Medicare multiple-procedure reduction — base codes 2; pays 100/50%
  2. Medicare multiple-therapy reduction (MPPR) — base codes 5; pays 100/50%
  3. custom SQL — Caps a charge's allowed amount when its billed units exceed a per-procedure maximum-allowed-units limit (a therapy/multiple-unit cap): if the code has a configured max-units value and billed Units exceed it, the allowed amount is scaled down proportionally (Allowed * maxUnits/units); otherwise Allowed passes through unchanged. — when CMS_Therapy_Codes True is present
  4. Medicare multiple-endoscopy reduction
  5. mid-level provider reduction (by NUCC taxonomy)
  6. modifier 22 present → 120% 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. custom SQL — ChargeLevelSqlAdjustment that bumps the already-computed allowed amount to 103% whenever the charge's revenue code is 278 (implant/device revenue code); otherwise leaves the charge unchanged. — when RevenueCode 278 is present
  17. cap each charge and the account total at 100% of billed charges
CIO Muncie ASC - CareSource (7.1.2024)6 base · 16 adj
Care Source Exchange
Facility · 1 named facilities · 2024-07-01 → 2999-12-31
Base terms — first match wins
  1. 140% of Medicare ASC
  2. flat $0 — when ProcedureCode 20930 is present
  3. flat $0 — when ProcedureCode 20936 is present
  4. flat $0 — when ProcedureCode 17999 is present
  5. flat $0 — when ProcedureCode 29826 is present
  6. flat $0 — when CMS_Status_Code Noncovered is present
Adjustments — all apply, in order
  1. Medicare multiple-procedure reduction — base codes 2; pays 100/50%
  2. Medicare multiple-therapy reduction (MPPR) — base codes 5; pays 100/50%
  3. custom SQL — Caps a charge's allowed amount when its billed units exceed a per-procedure maximum-allowed-units limit (a therapy/multiple-unit cap): if the code has a configured max-units value and billed Units exceed it, the allowed amount is scaled down proportionally (Allowed * maxUnits/units); otherwise Allowed passes through unchanged. — when CMS_Therapy_Codes True is present
  4. Medicare multiple-endoscopy reduction
  5. mid-level provider reduction (by NUCC taxonomy)
  6. modifier 22 present → 120% 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
CIO Muncie ASC - CareSource (7.1.2024)3 base · 16 adj
Cigna
Facility · 2 named facilities · 2024-07-01 → 2999-12-31
Base terms — first match wins
  1. 175% of Medicare ASC
  2. 55% of billed charges
  3. flat $0 — when CMS_Status_Code Noncovered is present
Adjustments — all apply, in order
  1. Medicare multiple-procedure reduction — base codes 2; pays 100/50%
  2. Medicare multiple-therapy reduction (MPPR) — base codes 5; pays 100/50%
  3. custom SQL — Caps a charge's allowed amount when its billed units exceed a per-procedure maximum-allowed-units limit (a therapy/multiple-unit cap): if the code has a configured max-units value and billed Units exceed it, the allowed amount is scaled down proportionally (Allowed * maxUnits/units); otherwise Allowed passes through unchanged. — when CMS_Therapy_Codes True is present
  4. Medicare multiple-endoscopy reduction
  5. mid-level provider reduction (by NUCC taxonomy)
  6. modifier 22 present → 120% 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
CIO Muncie ASC - Cigna (7.1.2024)2 base · 17 adj
Cigna
Facility · 2 named facilities · 2024-07-01 → 2999-12-31
Base terms — first match wins
  1. 100% of the Facility-Fees fee schedule
  2. flat $2650
Adjustments — all apply, in order
  1. Medicare multiple-procedure reduction — base codes 2; pays 100/50%
  2. Medicare multiple-therapy reduction (MPPR) — base codes 5; pays 100/50%
  3. custom SQL — Caps a charge's allowed amount when its billed units exceed a per-procedure maximum-allowed-units limit (a therapy/multiple-unit cap): if the code has a configured max-units value and billed Units exceed it, the allowed amount is scaled down proportionally (Allowed * maxUnits/units); otherwise Allowed passes through unchanged. — when CMS_Therapy_Codes True is present
  4. Medicare multiple-endoscopy reduction
  5. mid-level provider reduction (by NUCC taxonomy)
  6. modifier 22 present → 120% 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. custom SQL — A 15% surcharge on the already-computed Allowed amount when revenue code 278 is present on the charge. — when RevenueCode 278 is present
  17. cap each charge and the account total at 100% of billed charges
CIO Muncie ASC - ClaimDoc (7.1.2024)6 base · 16 adj
Claim DOC
Facility · 2 named facilities · 2024-07-01 → 2999-12-31
Base terms — first match wins
  1. 179% of Medicare ASC
  2. flat $0 — when ProcedureCode 20930 is present
  3. flat $0 — when ProcedureCode 20936 is present
  4. flat $0 — when ProcedureCode 17999 is present
  5. flat $0 — when ProcedureCode 29826 is present
  6. flat $0 — when CMS_Status_Code Noncovered is present
Adjustments — all apply, in order
  1. Medicare multiple-procedure reduction — base codes 2; pays 100/50%
  2. Medicare multiple-therapy reduction (MPPR) — base codes 5; pays 100/50%
  3. custom SQL — Caps a charge's allowed amount when its billed units exceed a per-procedure maximum-allowed-units limit (a therapy/multiple-unit cap): if the code has a configured max-units value and billed Units exceed it, the allowed amount is scaled down proportionally (Allowed * maxUnits/units); otherwise Allowed passes through unchanged. — when CMS_Therapy_Codes True is present
  4. Medicare multiple-endoscopy reduction
  5. mid-level provider reduction (by NUCC taxonomy)
  6. modifier 22 present → 120% 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
CIO Muncie ASC - Encore/Encircle (7.1.2024)1 base · 16 adj
Encore Encircle
Facility · 1 named facilities · 2024-07-01 → 2999-12-31
Base terms — first match wins
  1. 65% of billed charges
Adjustments — all apply, in order
  1. Medicare multiple-procedure reduction — base codes 2; pays 100/50%
  2. Medicare multiple-therapy reduction (MPPR) — base codes 5; pays 100/50%
  3. custom SQL — Caps a charge's allowed amount when its billed units exceed a per-procedure maximum-allowed-units limit (a therapy/multiple-unit cap): if the code has a configured max-units value and billed Units exceed it, the allowed amount is scaled down proportionally (Allowed * maxUnits/units); otherwise Allowed passes through unchanged. — when CMS_Therapy_Codes True is present
  4. Medicare multiple-endoscopy reduction
  5. mid-level provider reduction (by NUCC taxonomy)
  6. modifier 22 present → 120% 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
CIO Muncie ASC - Encore/Encircle (7.1.2024)2 base · 16 adj
Encore Encircle
Facility · 1 named facilities · 2024-07-01 → 2999-12-31
Base terms — first match wins
  1. 100% of billed charges — when ProcedureCode C1776 is present
  2. 65% of billed charges
Adjustments — all apply, in order
  1. Medicare multiple-procedure reduction — base codes 2; pays 100/50%
  2. Medicare multiple-therapy reduction (MPPR) — base codes 5; pays 100/50%
  3. custom SQL — Caps a charge's allowed amount when its billed units exceed a per-procedure maximum-allowed-units limit (a therapy/multiple-unit cap): if the code has a configured max-units value and billed Units exceed it, the allowed amount is scaled down proportionally (Allowed * maxUnits/units); otherwise Allowed passes through unchanged. — when CMS_Therapy_Codes True is present
  4. Medicare multiple-endoscopy reduction
  5. mid-level provider reduction (by NUCC taxonomy)
  6. modifier 22 present → 120% 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
CIO Muncie ASC - IU Health (7.1.2024)3 base · 16 adj
IU Senate Health
Facility · 1 named facilities · 2024-07-01 → 2999-12-31
Base terms — first match wins
  1. 105% of billed charges — when RevenueCode 278 is present
  2. 100% of the Facility-Fees fee schedule
  3. 50% of billed charges
Adjustments — all apply, in order
  1. Medicare multiple-procedure reduction — base codes 2; pays 100/50%
  2. Medicare multiple-therapy reduction (MPPR) — base codes 5; pays 100/50%
  3. custom SQL — Caps a charge's allowed amount when its billed units exceed a per-procedure maximum-allowed-units limit (a therapy/multiple-unit cap): if the code has a configured max-units value and billed Units exceed it, the allowed amount is scaled down proportionally (Allowed * maxUnits/units); otherwise Allowed passes through unchanged. — when CMS_Therapy_Codes True is present
  4. Medicare multiple-endoscopy reduction
  5. mid-level provider reduction (by NUCC taxonomy)
  6. modifier 22 present → 120% 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
CIO Muncie ASC - UHC (7.1.2024)1 base · 16 adj
United Healthcare
Facility · 2 named facilities · 2024-07-01 → 2999-12-31
Base terms — first match wins
  1. 100% of the Facility-Fees fee schedule
Adjustments — all apply, in order
  1. Medicare multiple-procedure reduction — base codes 2; pays 100/50%
  2. Medicare multiple-therapy reduction (MPPR) — base codes 5; pays 100/50%
  3. custom SQL — Caps a charge's allowed amount when its billed units exceed a per-procedure maximum-allowed-units limit (a therapy/multiple-unit cap): if the code has a configured max-units value and billed Units exceed it, the allowed amount is scaled down proportionally (Allowed * maxUnits/units); otherwise Allowed passes through unchanged. — when CMS_Therapy_Codes True is present
  4. Medicare multiple-endoscopy reduction
  5. mid-level provider reduction (by NUCC taxonomy)
  6. modifier 22 present → 120% 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
Charges1 base · 0 adj
Charges
Facility · Beacon ASC, CIO ASC, Non-OA Indiana, Non-OA Ohio, OA Indiana, OA JV, OA Ohio · 2020-01-01 → 2999-12-31
Charges
Profee · Beacon ASC, CIO ASC, Non-OA Indiana, Non-OA Ohio, OA Indiana, OA JV, OA Ohio · 2020-01-01 → 2999-12-31
Base terms — first match wins
  1. custom SQL — Looks up a chargemaster rate for the code, profee-vs-facility bill type, and date range from the customer's transformed chargemaster feed, keyed to whether the facility is a clinic.
Charges-SBO1 base · 0 adj
Charges
Facility · SBO · 2023-01-01 → 2999-12-31
Charges
Profee · SBO · 2023-01-01 → 2999-12-31
Base terms — first match wins
  1. custom SQL — Athena department-level charge-master fee lookup for the facility's mapped Athena fee schedule and procedure code.
Cigna-Facility4 base · 17 adj
Cigna
Facility · Beacon ASC · 2012-02-01 → 2099-12-31
Base terms — first match wins
  1. 100% of the Fixed-Fees-Carveout fee schedule
  2. 0% of billed charges — when RevenueCode 275 is present; RevenueCode 276 is present; RevenueCode 278 is present
  3. 100% of the ASC-Grouper fee schedule
  4. 0% of billed charges
Adjustments — all apply, in order
  1. Medicare multiple-procedure reduction — base codes 0, 2, 3; pays 100/50/25/0/0/0%
  2. rescale to 85% of the running amount — when Mid-Level-Providers Mid-Level is present
  3. custom SQL — Caps a charge's allowed amount when its billed units exceed a per-procedure maximum-allowed-units limit (a therapy/multiple-unit cap): if the code has a configured max-units value and billed Units exceed it, the allowed amount is scaled down proportionally (Allowed * maxUnits/units); otherwise Allowed passes through unchanged. — when CMS_Therapy_Codes True is present
  4. modifier 22 present → 120% 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. modifier 62 present → 63% 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 25 present → 50% of the running amount
  15. modifier 53 present → 50% of the running amount
  16. modifier 55 present → 20% of the running amount
  17. cap each charge and the account total at 100% of billed charges
Cigna-OAIN-Profee-20263 base · 15 adj
Cigna
Profee · CIO ASC, Non-OA Indiana, OA Indiana · 2026-04-15 → 2099-12-31
Base terms — first match wins
  1. 100% of the OAIN-Cigna-Profee-Hospital fee schedule — when FacilityType in ASC, Hospital
  2. 100% of the OAIN-Cigna-Profee fee schedule — when FacilityType in Clinic
  3. 50% of billed charges
Adjustments — all apply, in order
  1. Medicare multiple-procedure reduction — base codes 2; pays 100/50%
  2. Medicare multiple-therapy reduction (MPPR) — base codes 5; pays 100/50%
  3. Medicare multiple-endoscopy reduction
  4. mid-level provider reduction (by NUCC taxonomy)
  5. modifier 22 present → 120% 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
Cigna-Ohio-OA-Profee-Clinic3 base · 19 adj
Cigna
Profee · Beacon ASC, Non-OA Ohio, OA JV, OA Ohio · 2025-01-01 → 2999-12-31
Base terms — first match wins
  1. 100% of Medicare drug
  2. 100% of the Cigna-Profee-Fees fee schedule
  3. 50% of billed charges
Adjustments — all apply, in order
  1. rescale to 85% of the running amount — when Mid-Level-Providers Mid-Level is present
  2. Medicare multiple-procedure reduction — base codes 2; pays 100/50%
  3. Medicare multiple-therapy reduction (MPPR) — base codes 5; pays 100/50%
  4. custom SQL — Caps a charge's allowed amount when its billed units exceed a per-procedure maximum-allowed-units limit (a therapy/multiple-unit cap): if the code has a configured max-units value and billed Units exceed it, the allowed amount is scaled down proportionally (Allowed * maxUnits/units); otherwise Allowed passes through unchanged. — when CMS_Therapy_Codes True is present
  5. Medicare multiple-endoscopy reduction
  6. modifier 22 present → 120% 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 → 70% of the running amount
  10. modifier 62 present → 63% 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 → 14% of the running amount
  16. modifier 25 present → 50% of the running amount
  17. modifier 53 present → 50% of the running amount
  18. modifier 55 present → 20% of the running amount
  19. cap each charge and the account total at 100% of billed charges
Cigna-Ohio-OA-Profee-Hospital3 base · 19 adj
Cigna
Profee · 12 named facilities · 2025-01-01 → 2999-12-31
Base terms — first match wins
  1. 100% of Medicare drug
  2. 100% of the Cigna-Facility-Profee-Fees fee schedule
  3. 50% of billed charges
Adjustments — all apply, in order
  1. rescale to 85% of the running amount — when Mid-Level-Providers Mid-Level is present
  2. Medicare multiple-procedure reduction — base codes 2; pays 100/50%
  3. Medicare multiple-therapy reduction (MPPR) — base codes 5; pays 100/50%
  4. custom SQL — Caps a charge's allowed amount when its billed units exceed a per-procedure maximum-allowed-units limit (a therapy/multiple-unit cap): if the code has a configured max-units value and billed Units exceed it, the allowed amount is scaled down proportionally (Allowed * maxUnits/units); otherwise Allowed passes through unchanged. — when CMS_Therapy_Codes True is present
  5. Medicare multiple-endoscopy reduction
  6. modifier 22 present → 120% 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 → 70% of the running amount
  10. modifier 62 present → 63% 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 → 14% of the running amount
  16. modifier 25 present → 50% of the running amount
  17. modifier 53 present → 50% of the running amount
  18. modifier 55 present → 20% of the running amount
  19. cap each charge and the account total at 100% of billed charges
Cigna-Profee-Clinic5 base · 19 adj
Cigna
Profee · 40 named facilities · 2014-05-15 → 2999-12-31
Cigna
Profee · 25 named facilities · 2014-05-15 → 2024-12-31
Base terms — first match wins
  1. computed expression (operands follow)
  2. 100% of the Profee-Clinic fee schedule
  3. Multiply 100% of the Fixed-Fees-Percentage fee schedule
  4. 100% of the Fixed-Fees-Carveout fee schedule
  5. 50% of billed charges
Adjustments — all apply, in order
  1. rescale to 85% of the running amount — when Mid-Level-Providers Mid-Level is present
  2. Medicare multiple-procedure reduction — base codes 2; pays 100/50%
  3. Medicare multiple-therapy reduction (MPPR) — base codes 5; pays 100/50%
  4. custom SQL — Caps a charge's allowed amount when its billed units exceed a per-procedure maximum-allowed-units limit (a therapy/multiple-unit cap): if the code has a configured max-units value and billed Units exceed it, the allowed amount is scaled down proportionally (Allowed * maxUnits/units); otherwise Allowed passes through unchanged. — when CMS_Therapy_Codes True is present
  5. Medicare multiple-endoscopy reduction
  6. modifier 22 present → 120% 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 → 70% of the running amount
  10. modifier 62 present → 63% 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 → 14% of the running amount
  16. modifier 25 present → 50% of the running amount
  17. modifier 53 present → 50% of the running amount
  18. modifier 55 present → 20% of the running amount
  19. cap each charge and the account total at 100% of billed charges
Cigna-Profee-Clinic-With-Medicare-Drug6 base · 19 adj
Cigna
Profee · 106 named facilities · 2014-05-15 → 2024-12-31
Base terms — first match wins
  1. 100% of Medicare drug
  2. computed expression (operands follow)
  3. 100% of the Profee-Clinic fee schedule
  4. Multiply 100% of the Fixed-Fees-Percentage fee schedule
  5. 100% of the Fixed-Fees-Carveout fee schedule
  6. 50% of billed charges
Adjustments — all apply, in order
  1. rescale to 85% of the running amount — when Mid-Level-Providers Mid-Level is present
  2. Medicare multiple-procedure reduction — base codes 2; pays 100/50%
  3. Medicare multiple-therapy reduction (MPPR) — base codes 5; pays 100/50%
  4. custom SQL — Caps a charge's allowed amount when its billed units exceed a per-procedure maximum-allowed-units limit (a therapy/multiple-unit cap): if the code has a configured max-units value and billed Units exceed it, the allowed amount is scaled down proportionally (Allowed * maxUnits/units); otherwise Allowed passes through unchanged. — when CMS_Therapy_Codes True is present
  5. Medicare multiple-endoscopy reduction
  6. modifier 22 present → 120% 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 → 70% of the running amount
  10. modifier 62 present → 63% 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 → 14% of the running amount
  16. modifier 25 present → 50% of the running amount
  17. modifier 53 present → 50% of the running amount
  18. modifier 55 present → 20% of the running amount
  19. cap each charge and the account total at 100% of billed charges
Cigna-Profee-Hospital2 base · 19 adj
Cigna
Profee · 199 named facilities · 2025-01-01 → 2999-12-31
Base terms — first match wins
  1. 100% of the Cigna-Facility-Profee-Fees fee schedule
  2. 50% of billed charges
Adjustments — all apply, in order
  1. rescale to 85% of the running amount — when Mid-Level-Providers Mid-Level is present
  2. Medicare multiple-procedure reduction — base codes 2; pays 100/50%
  3. Medicare multiple-therapy reduction (MPPR) — base codes 5; pays 100/50%
  4. custom SQL — Caps a charge's allowed amount when its billed units exceed a per-procedure maximum-allowed-units limit (a therapy/multiple-unit cap): if the code has a configured max-units value and billed Units exceed it, the allowed amount is scaled down proportionally (Allowed * maxUnits/units); otherwise Allowed passes through unchanged. — when CMS_Therapy_Codes True is present
  5. Medicare multiple-endoscopy reduction
  6. modifier 22 present → 120% 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 → 70% of the running amount
  10. modifier 62 present → 63% 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 → 14% of the running amount
  16. modifier 25 present → 50% of the running amount
  17. modifier 53 present → 50% of the running amount
  18. modifier 55 present → 20% of the running amount
  19. cap each charge and the account total at 100% of billed charges
Cigna-Profee-Hospital5 base · 19 adj
Cigna
Profee · 191 named facilities · 2014-05-15 → 2024-12-31
Cigna
Profee · 15 named facilities · 2014-05-15 → 2999-12-31
Base terms — first match wins
  1. computed expression (operands follow)
  2. 100% of the Profee-Hospital fee schedule
  3. Multiply 100% of the Fixed-Fees-Percentage fee schedule
  4. 100% of the Fixed-Fees-Carveout fee schedule
  5. 50% of billed charges
Adjustments — all apply, in order
  1. rescale to 85% of the running amount — when Mid-Level-Providers Mid-Level is present
  2. Medicare multiple-procedure reduction — base codes 2; pays 100/50%
  3. Medicare multiple-therapy reduction (MPPR) — base codes 5; pays 100/50%
  4. custom SQL — Caps a charge's allowed amount when its billed units exceed a per-procedure maximum-allowed-units limit (a therapy/multiple-unit cap): if the code has a configured max-units value and billed Units exceed it, the allowed amount is scaled down proportionally (Allowed * maxUnits/units); otherwise Allowed passes through unchanged. — when CMS_Therapy_Codes True is present
  5. Medicare multiple-endoscopy reduction
  6. modifier 22 present → 120% 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 → 70% of the running amount
  10. modifier 62 present → 63% 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 → 14% of the running amount
  16. modifier 25 present → 50% of the running amount
  17. modifier 53 present → 50% of the running amount
  18. modifier 55 present → 20% of the running amount
  19. cap each charge and the account total at 100% of billed charges
Cigna-Profee-Hospital-With-Medicare-Drug6 base · 19 adj
Cigna
Profee · 5 named facilities · 2014-05-15 → 2024-12-31
Base terms — first match wins
  1. 100% of Medicare drug
  2. computed expression (operands follow)
  3. 100% of the Profee-Hospital fee schedule
  4. Multiply 100% of the Fixed-Fees-Percentage fee schedule
  5. 100% of the Fixed-Fees-Carveout fee schedule
  6. 50% of billed charges
Adjustments — all apply, in order
  1. rescale to 85% of the running amount — when Mid-Level-Providers Mid-Level is present
  2. Medicare multiple-procedure reduction — base codes 2; pays 100/50%
  3. Medicare multiple-therapy reduction (MPPR) — base codes 5; pays 100/50%
  4. custom SQL — Caps a charge's allowed amount when its billed units exceed a per-procedure maximum-allowed-units limit (a therapy/multiple-unit cap): if the code has a configured max-units value and billed Units exceed it, the allowed amount is scaled down proportionally (Allowed * maxUnits/units); otherwise Allowed passes through unchanged. — when CMS_Therapy_Codes True is present
  5. Medicare multiple-endoscopy reduction
  6. modifier 22 present → 120% 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 → 70% of the running amount
  10. modifier 62 present → 63% 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 → 14% of the running amount
  16. modifier 25 present → 50% of the running amount
  17. modifier 53 present → 50% of the running amount
  18. modifier 55 present → 20% of the running amount
  19. cap each charge and the account total at 100% of billed charges
Cigna-Profee-OAIN3 base · 14 adj
Cigna
Profee · CIO ASC, Non-OA Indiana, OA Indiana · 2023-01-01 → 2026-04-14
Base terms — first match wins
  1. case rate from Fixed-Fees-Case-Rate (All-level codes)
  2. 100% of the Profee-Clinic fee schedule
  3. 80% 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. rescale to 85% of the running amount — when Mid-Level-Providers Mid-Level is present
  4. modifier 22 present → 120% 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 → 13.6% of the running amount
  14. cap each charge and the account total at 100% of billed charges
Cigna-Profee-OAIN-Hospital3 base · 14 adj
Cigna
Profee · Non-OA Indiana, OA Indiana, ASC, Hospital · 2023-01-01 → 2026-04-14
Base terms — first match wins
  1. case rate from Fixed-Fees-Case-Rate (All-level codes)
  2. 100% of the OAIN-Cigna-Profee-Hospital fee schedule
  3. 80% 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. rescale to 85% of the running amount — when Mid-Level-Providers Mid-Level is present
  4. modifier 22 present → 120% 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 → 13.6% of the running amount
  14. cap each charge and the account total at 100% of billed charges
Community-Health-Alliance-Profee2 base · 18 adj
Community Health Alliance
Profee · CIO ASC, Non-OA Indiana, OA Indiana · 2025-01-01 → 2999-12-31
Base terms — first match wins
  1. 100% of the EncoreCombined-Fixed-Fees-SBO fee schedule
  2. 75% of billed charges
Adjustments — all apply, in order
  1. rescale to 85% of the running amount — when Mid-Level-Providers Mid-Level is present
  2. Medicare multiple-procedure reduction — base codes 2; pays 100/50%
  3. Medicare multiple-therapy reduction (MPPR) — base codes 5; pays 100/50%
  4. Medicare multiple-endoscopy reduction
  5. modifier 22 present → 120% 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. modifier 62 present → 63% 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 25 present → 50% of the running amount
  16. modifier 53 present → 50% of the running amount
  17. modifier 55 present → 20% of the running amount
  18. cap each charge and the account total at 100% of billed charges
Custom-Design-Benefits-Profee1 base · 18 adj
Custom Design Benefits
Profee · CIO ASC, Non-OA Indiana, OA Indiana · 2025-01-01 → 2999-12-31
Base terms — first match wins
  1. 100% of the EncoreCombined-Fixed-Fees-SBO fee schedule
Adjustments — all apply, in order
  1. rescale to 85% of the running amount — when Mid-Level-Providers Mid-Level is present
  2. Medicare multiple-procedure reduction — base codes 2; pays 100/50%
  3. Medicare multiple-therapy reduction (MPPR) — base codes 5; pays 100/50%
  4. Medicare multiple-endoscopy reduction
  5. modifier 22 present → 120% 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. modifier 62 present → 63% 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 25 present → 50% of the running amount
  16. modifier 53 present → 50% of the running amount
  17. modifier 55 present → 20% of the running amount
  18. cap each charge and the account total at 100% of billed charges
Devoted-Health-Medicare-Advantage-ASC-SBO-CIO6 base · 16 adj
Devoted Health Medicare Advantage
Facility · 5 named facilities · 2026-01-01 → 2026-12-31
Base terms — first match wins
  1. 102% of Medicare ASC
  2. flat $0 — when ProcedureCode 20930 is present
  3. flat $0 — when ProcedureCode 20936 is present
  4. flat $0 — when ProcedureCode 17999 is present
  5. flat $0 — when ProcedureCode 29826 is present
  6. 20% of billed charges
Adjustments — all apply, in order
  1. Medicare multiple-procedure reduction — base codes 2; pays 100/50%
  2. Medicare multiple-therapy reduction (MPPR) — base codes 5; pays 100/50%
  3. custom SQL — Caps a charge's allowed amount when its billed units exceed a per-procedure maximum-allowed-units limit (a therapy/multiple-unit cap): if the code has a configured max-units value and billed Units exceed it, the allowed amount is scaled down proportionally (Allowed * maxUnits/units); otherwise Allowed passes through unchanged. — when CMS_Therapy_Codes True is present
  4. Medicare multiple-endoscopy reduction
  5. mid-level provider reduction (by NUCC taxonomy)
  6. modifier 22 present → 120% 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
Devoted-Health-Medicare-Advantage-ASC-SBO-CIO-20276 base · 16 adj
Devoted Health Medicare Advantage
Facility · 5 named facilities · 2027-01-01 → 2027-12-31
Base terms — first match wins
  1. 101% of Medicare ASC
  2. flat $0 — when ProcedureCode 20930 is present
  3. flat $0 — when ProcedureCode 20936 is present
  4. flat $0 — when ProcedureCode 17999 is present
  5. flat $0 — when ProcedureCode 29826 is present
  6. 20% of billed charges
Adjustments — all apply, in order
  1. Medicare multiple-procedure reduction — base codes 2; pays 100/50%
  2. Medicare multiple-therapy reduction (MPPR) — base codes 5; pays 100/50%
  3. custom SQL — Caps a charge's allowed amount when its billed units exceed a per-procedure maximum-allowed-units limit (a therapy/multiple-unit cap): if the code has a configured max-units value and billed Units exceed it, the allowed amount is scaled down proportionally (Allowed * maxUnits/units); otherwise Allowed passes through unchanged. — when CMS_Therapy_Codes True is present
  4. Medicare multiple-endoscopy reduction
  5. mid-level provider reduction (by NUCC taxonomy)
  6. modifier 22 present → 120% 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
Devoted-Health-Medicare-Advantage-ASC-SBO-CIO-20286 base · 16 adj
Devoted Health Medicare Advantage
Facility · 5 named facilities · 2028-01-01 → 2999-12-31
Base terms — first match wins
  1. 100% of Medicare ASC
  2. flat $0 — when ProcedureCode 20930 is present
  3. flat $0 — when ProcedureCode 20936 is present
  4. flat $0 — when ProcedureCode 17999 is present
  5. flat $0 — when ProcedureCode 29826 is present
  6. 20% of billed charges
Adjustments — all apply, in order
  1. Medicare multiple-procedure reduction — base codes 2; pays 100/50%
  2. Medicare multiple-therapy reduction (MPPR) — base codes 5; pays 100/50%
  3. custom SQL — Caps a charge's allowed amount when its billed units exceed a per-procedure maximum-allowed-units limit (a therapy/multiple-unit cap): if the code has a configured max-units value and billed Units exceed it, the allowed amount is scaled down proportionally (Allowed * maxUnits/units); otherwise Allowed passes through unchanged. — when CMS_Therapy_Codes True is present
  4. Medicare multiple-endoscopy reduction
  5. mid-level provider reduction (by NUCC taxonomy)
  6. modifier 22 present → 120% 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
Devoted-Health-Medicare-Advantage-SBO-CIO8 base · 16 adj
Devoted Health Medicare Advantage
Profee · 46 named facilities · 2026-01-01 → 2026-12-31
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. flat $0 — when ProcedureCode 20930 is present
  6. flat $0 — when ProcedureCode 20936 is present
  7. flat $0 — when ProcedureCode 17999 is present
  8. 20% of billed charges
Adjustments — all apply, in order
  1. Medicare multiple-procedure reduction — base codes 2; pays 100/50%
  2. custom SQL — Caps a charge's allowed amount when its billed units exceed a per-procedure maximum-allowed-units limit (a therapy/multiple-unit cap): if the code has a configured max-units value and billed Units exceed it, the allowed amount is scaled down proportionally (Allowed * maxUnits/units); otherwise Allowed passes through unchanged. — when CMS_Therapy_Codes True is present
  3. Medicare multiple-therapy reduction (MPPR) — base codes 5; pays 100/50%
  4. Medicare multiple-endoscopy reduction
  5. mid-level provider reduction (by NUCC taxonomy)
  6. modifier 22 present → 120% 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
Devoted-Health-Medicare-Advantage-SBO-CIO-20278 base · 16 adj
Devoted Health Medicare Advantage
Profee · 46 named facilities · 2027-01-01 → 2027-12-31
Base terms — first match wins
  1. 101% of Medicare lab
  2. 101% of Medicare drug
  3. 101% of Medicare DME
  4. 101% of Medicare RVU
  5. flat $0 — when ProcedureCode 20930 is present
  6. flat $0 — when ProcedureCode 20936 is present
  7. flat $0 — when ProcedureCode 17999 is present
  8. 20% of billed charges
Adjustments — all apply, in order
  1. Medicare multiple-procedure reduction — base codes 2; pays 100/50%
  2. custom SQL — Caps a charge's allowed amount when its billed units exceed a per-procedure maximum-allowed-units limit (a therapy/multiple-unit cap): if the code has a configured max-units value and billed Units exceed it, the allowed amount is scaled down proportionally (Allowed * maxUnits/units); otherwise Allowed passes through unchanged. — when CMS_Therapy_Codes True is present
  3. Medicare multiple-therapy reduction (MPPR) — base codes 5; pays 100/50%
  4. Medicare multiple-endoscopy reduction
  5. mid-level provider reduction (by NUCC taxonomy)
  6. modifier 22 present → 120% 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
Devoted-Health-Medicare-Advantage-SBO-CIO-20288 base · 16 adj
Devoted Health Medicare Advantage
Profee · 46 named facilities · 2028-01-01 → 2999-12-31
Base terms — first match wins
  1. 100% of Medicare lab
  2. 100% of Medicare drug
  3. 100% of Medicare DME
  4. 100% of Medicare RVU
  5. flat $0 — when ProcedureCode 20930 is present
  6. flat $0 — when ProcedureCode 20936 is present
  7. flat $0 — when ProcedureCode 17999 is present
  8. 20% of billed charges
Adjustments — all apply, in order
  1. Medicare multiple-procedure reduction — base codes 2; pays 100/50%
  2. custom SQL — Caps a charge's allowed amount when its billed units exceed a per-procedure maximum-allowed-units limit (a therapy/multiple-unit cap): if the code has a configured max-units value and billed Units exceed it, the allowed amount is scaled down proportionally (Allowed * maxUnits/units); otherwise Allowed passes through unchanged. — when CMS_Therapy_Codes True is present
  3. Medicare multiple-therapy reduction (MPPR) — base codes 5; pays 100/50%
  4. Medicare multiple-endoscopy reduction
  5. mid-level provider reduction (by NUCC taxonomy)
  6. modifier 22 present → 120% 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
Encore-Combined-Profee1 base · 18 adj
Encore Combined
Profee · 85 named facilities · 2025-01-01 → 2999-12-31
Base terms — first match wins
  1. 100% of the EncoreCombined-Fixed-Fees-SBO fee schedule
Adjustments — all apply, in order
  1. rescale to 85% of the running amount — when Mid-Level-Providers Mid-Level is present
  2. Medicare multiple-procedure reduction — base codes 2; pays 100/50%
  3. Medicare multiple-therapy reduction (MPPR) — base codes 5; pays 100/50%
  4. Medicare multiple-endoscopy reduction
  5. modifier 22 present → 120% 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. modifier 62 present → 63% 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 25 present → 50% of the running amount
  16. modifier 53 present → 50% of the running amount
  17. modifier 55 present → 20% of the running amount
  18. cap each charge and the account total at 100% of billed charges
Humana-Medicare-Clinic7 base · 18 adj
Humana
Profee · Beacon ASC, Non-OA Ohio, OA JV, OA Ohio · 2014-05-15 → 2999-12-31
Base terms — first match wins
  1. 100% of Medicare drug
  2. 100% of Medicare DME
  3. 100% of Medicare anesthesia
  4. 100% of Medicare RVU
  5. flat $0 — when ProcedureCode 20930 is present
  6. flat $0 — when ProcedureCode 20936 is present
  7. flat $0 — when ProcedureCode 17999 is present
Adjustments — all apply, in order
  1. rescale to 85% of the running amount — when Mid-Level-Providers Mid-Level is present
  2. Medicare multiple-procedure reduction — base codes 2; pays 100/50%
  3. Medicare multiple-therapy reduction (MPPR) — base codes 5; pays 100/50%
  4. Medicare multiple-endoscopy reduction
  5. modifier 22 present → 120% 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. modifier 62 present → 63% 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 25 present → 50% of the running amount
  16. modifier 53 present → 50% of the running amount
  17. modifier 55 present → 20% of the running amount
  18. cap each charge and the account total at 100% of billed charges
MMO-ASC2 base · 16 adj
MMO
Facility · 661 named facilities · 2024-12-01 → 2999-12-31
Base terms — first match wins
  1. 100% of the Facility-Fees fee schedule
  2. 65% of billed charges
Adjustments — all apply, in order
  1. rescale to 85% of the running amount — when Mid-Level-Providers Mid-Level is present
  2. multiple-procedure reduction (contract rules) — base codes 2; pays 100/50%
  3. modifier 22 present → 120% of the running amount
  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 62 present → 63% of the running amount
  8. modifier 78 present → 70% of the running amount
  9. modifier 80 present → 16% of the running amount
  10. modifier 81 present → 16% of the running amount
  11. modifier 82 present → 16% of the running amount
  12. modifier AS present → 14% of the running amount
  13. modifier 25 present → 50% of the running amount
  14. modifier 53 present → 50% of the running amount
  15. modifier 55 present → 20% of the running amount
  16. cap each charge and the account total at 100% of billed charges
MMO-ASC6 base · 16 adj
MMO
Facility · 668 named facilities · 2023-03-01 → 2024-11-30
Base terms — first match wins
  1. 100% of the Fixed-Fees fee schedule
  2. 100% of the ASC-Grouper fee schedule
  3. 100% of billed charges — when RevenueCode 274 is present
  4. 100% of billed charges — when RevenueCode 275 is present
  5. 100% of billed charges — when RevenueCode 278 is present
  6. 65% of billed charges
Adjustments — all apply, in order
  1. rescale to 85% of the running amount — when Mid-Level-Providers Mid-Level is present
  2. multiple-procedure reduction (contract rules) — base codes 2; pays 100/50%
  3. modifier 22 present → 120% of the running amount
  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 62 present → 63% of the running amount
  8. modifier 78 present → 70% of the running amount
  9. modifier 80 present → 16% of the running amount
  10. modifier 81 present → 16% of the running amount
  11. modifier 82 present → 16% of the running amount
  12. modifier AS present → 14% of the running amount
  13. modifier 25 present → 50% of the running amount
  14. modifier 53 present → 50% of the running amount
  15. modifier 55 present → 20% of the running amount
  16. cap each charge and the account total at 100% of billed charges
MMO-Profee-Clinic4 base · 17 adj
MMO
Profee · 170 named facilities · 2022-10-01 → 2999-12-31
Base terms — first match wins
  1. 100% of the Profee-Clinic fee schedule
  2. flat $0 — when ProcedureCode 20930 is present
  3. flat $0 — when ProcedureCode 20936 is present
  4. flat $0 — when ProcedureCode 17999 is present
Adjustments — all apply, in order
  1. Medicare multiple-procedure reduction — base codes 2; pays 100/50%
  2. Medicare multiple-therapy reduction (MPPR) — base codes 5; pays 100/50%
  3. rescale to 85% of the running amount — when Mid-Level-Providers Mid-Level is present
  4. modifier 22 present → 120% 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. modifier 62 present → 63% 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 25 present → 50% of the running amount
  15. modifier 53 present → 50% of the running amount
  16. modifier 55 present → 20% of the running amount
  17. cap each charge and the account total at 100% of billed charges
MMO-Profee-Clinic-OH-OA5 base · 17 adj
MMO
Profee · 141 named facilities · 2022-10-01 → 2999-12-31
Base terms — first match wins
  1. 100% of Medicare drug
  2. 100% of the Profee-Clinic fee schedule
  3. flat $0 — when ProcedureCode 20930 is present
  4. flat $0 — when ProcedureCode 20936 is present
  5. flat $0 — when ProcedureCode 17999 is present
Adjustments — all apply, in order
  1. Medicare multiple-procedure reduction — base codes 2; pays 100/50%
  2. Medicare multiple-therapy reduction (MPPR) — base codes 5; pays 100/50%
  3. rescale to 85% of the running amount — when Mid-Level-Providers Mid-Level is present
  4. modifier 22 present → 120% 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. modifier 62 present → 63% 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 25 present → 50% of the running amount
  15. modifier 53 present → 50% of the running amount
  16. modifier 55 present → 20% of the running amount
  17. cap each charge and the account total at 100% of billed charges
MMO-Profee-Facility4 base · 17 adj
MMO
Profee · 324 named facilities · 2022-10-01 → 2999-12-31
Base terms — first match wins
  1. 100% of the Profee-Hospital fee schedule
  2. flat $0 — when ProcedureCode 20930 is present
  3. flat $0 — when ProcedureCode 20936 is present
  4. flat $0 — when ProcedureCode 17999 is present
Adjustments — all apply, in order
  1. Medicare multiple-procedure reduction — base codes 2; pays 100/50%
  2. Medicare multiple-therapy reduction (MPPR) — base codes 5; pays 100/50%
  3. rescale to 85% of the running amount — when Mid-Level-Providers Mid-Level is present
  4. modifier 22 present → 120% 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. modifier 62 present → 63% 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 25 present → 50% of the running amount
  15. modifier 53 present → 50% of the running amount
  16. modifier 55 present → 20% of the running amount
  17. cap each charge and the account total at 100% of billed charges
MMO-Profee-Facility-OH-OA5 base · 17 adj
MMO
Profee · 7 named facilities · 2022-10-01 → 2999-12-31
Base terms — first match wins
  1. 100% of Medicare drug
  2. 100% of the Profee-Hospital fee schedule
  3. flat $0 — when ProcedureCode 20930 is present
  4. flat $0 — when ProcedureCode 20936 is present
  5. flat $0 — when ProcedureCode 17999 is present
Adjustments — all apply, in order
  1. Medicare multiple-procedure reduction — base codes 2; pays 100/50%
  2. Medicare multiple-therapy reduction (MPPR) — base codes 5; pays 100/50%
  3. rescale to 85% of the running amount — when Mid-Level-Providers Mid-Level is present
  4. modifier 22 present → 120% 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. modifier 62 present → 63% 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 25 present → 50% of the running amount
  15. modifier 53 present → 50% of the running amount
  16. modifier 55 present → 20% of the running amount
  17. cap each charge and the account total at 100% of billed charges
Medicare8 base · 16 adj
AARP Medicare
Profee · 895 named facilities · 2022-01-01 → 2999-12-31
Ambetter
Profee · 195 named facilities · 2022-01-01 → 2999-12-31
BCBS Medicare
Profee · 895 named facilities · 2022-01-01 → 2999-12-31
Buckeye Medicare
Profee · 406 named facilities · 2022-01-01 → 2999-12-31
Caresource Medicare
Profee · 895 named facilities · 2022-01-01 → 2999-12-31
Cigna Medicare
Profee · 895 named facilities · 2022-01-01 → 2999-12-31
Devoted Health Medicare Advantage
Profee · 100 named facilities · 2026-01-01 → 2999-12-31
Humana Medicare
Profee · 895 named facilities · 2022-01-01 → 2999-12-31
IU Health Medicare Advantage
Profee · 895 named facilities · 2022-01-01 → 2999-12-31
Medical Mutual Medicare Advantage
Profee · 895 named facilities · 2022-01-01 → 2999-12-31
Medicare
Profee · 895 named facilities · 2022-01-01 → 2999-12-31
Medigold
Profee · 895 named facilities · 2022-01-01 → 2999-12-31
Molina Medicare
Profee · 895 named facilities · 2022-01-01 → 2999-12-31
Optum Medicare
Profee · 895 named facilities · 2022-01-01 → 2999-12-31
UMWA H And R Funds
Profee · 895 named facilities · 2022-01-01 → 2999-12-31
United Healthcare Medicare
Profee · 895 named facilities · 2022-01-01 → 2999-12-31
Wellcare Medicare
Profee · 895 named facilities · 2022-01-01 → 2999-12-31
Zing PPO Medicare Advantage
Profee · Beacon ASC, Non-OA Ohio, OA JV, OA Ohio · 2022-01-01 → 2999-12-31
Anthem Medicare Advantage
Profee · CIO ASC, Non-OA Indiana, OA Indiana · 2022-01-01 → 2999-12-31
Base terms — first match wins
  1. 100% of Medicare lab
  2. 100% of Medicare drug
  3. 100% of Medicare DME
  4. 100% of Medicare RVU
  5. flat $0 — when ProcedureCode 20930 is present
  6. flat $0 — when ProcedureCode 20936 is present
  7. flat $0 — when ProcedureCode 17999 is present
  8. flat $0 — when CMS_Status_Code Noncovered is present
Adjustments — all apply, in order
  1. Medicare multiple-procedure reduction — base codes 2; pays 100/50%
  2. custom SQL — Caps a charge's allowed amount when its billed units exceed a per-procedure maximum-allowed-units limit (a therapy/multiple-unit cap): if the code has a configured max-units value and billed Units exceed it, the allowed amount is scaled down proportionally (Allowed * maxUnits/units); otherwise Allowed passes through unchanged. — when CMS_Therapy_Codes True is present
  3. Medicare multiple-therapy reduction (MPPR) — base codes 5; pays 100/50%
  4. Medicare multiple-endoscopy reduction
  5. mid-level provider reduction (by NUCC taxonomy)
  6. modifier 22 present → 120% 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-ASC7 base · 15 adj
Buckeye Medicare
Facility · 406 named facilities · 2022-01-01 → 2999-12-31
Caresource Medicare
Facility · 406 named facilities · 2022-01-01 → 2999-12-31
Devoted Health Medicare Advantage
Facility · 100 named facilities · 2026-01-01 → 2999-12-31
Humana
Facility · 254 named facilities · 2022-01-01 → 2999-12-31
Humana Medicare
Facility · 406 named facilities · 2022-01-01 → 2999-12-31
IU Health Medicare Advantage
Facility · 406 named facilities · 2022-01-01 → 2999-12-31
Medical Mutual Medicare Advantage
Facility · 406 named facilities · 2022-01-01 → 2999-12-31
Medicare
Facility · 895 named facilities · 2022-01-01 → 2999-12-31
Medigold
Facility · 406 named facilities · 2022-01-01 → 2999-12-31
Molina Medicare
Facility · 406 named facilities · 2022-01-01 → 2999-12-31
UMWA H And R Funds
Facility · 406 named facilities · 2022-01-01 → 2999-12-31
Wellcare Medicare
Facility · 406 named facilities · 2022-01-01 → 2999-12-31
Zing PPO Medicare Advantage
Facility · 406 named facilities · 2022-01-01 → 2999-12-31
Base terms — first match wins
  1. 100% of Medicare ASC
  2. 100% of Medicare ASC — when Facility 097E0A62-440D-4643-AAA2-317CC38A39D4 is present
  3. flat $0 — when ProcedureCode 20930 is present
  4. flat $0 — when ProcedureCode 20936 is present
  5. flat $0 — when ProcedureCode 17999 is present
  6. flat $0 — when ProcedureCode 29826 is present
  7. flat $0 — when CMS_Status_Code Noncovered is present
Adjustments — all apply, in order
  1. Medicare multiple-procedure reduction — base codes 2, 3; pays 100/50%
  2. Medicare multiple-therapy reduction (MPPR) — base codes 5; pays 100/50%
  3. custom SQL — Caps a charge's allowed amount when its billed units exceed a per-procedure maximum-allowed-units limit (a therapy/multiple-unit cap): if the code has a configured max-units value and billed Units exceed it, the allowed amount is scaled down proportionally (Allowed * maxUnits/units); otherwise Allowed passes through unchanged. — when CMS_Therapy_Codes True is present
  4. mid-level provider reduction (by NUCC taxonomy)
  5. modifier 22 present → 120% 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
OAIN-Anthem-BCBS-Profee-Clinic1 base · 15 adj
Anthem BCBS
Profee · CIO ASC, Non-OA Indiana, OA Indiana, Clinic · 2023-01-01 → 2999-12-31
Base terms — first match wins
  1. 100% of the OAIndiana-Anthem-BCBS-Profee-Clinic fee schedule
Adjustments — all apply, in order
  1. Medicare multiple-procedure reduction — base codes 2; pays 100/50%
  2. Medicare multiple-therapy reduction (MPPR) — base codes 5; pays 100/50%
  3. Medicare multiple-endoscopy reduction
  4. mid-level provider reduction (by NUCC taxonomy)
  5. modifier 22 present → 120% 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
OAIN-Anthem-BCBS-Profee-Hospital1 base · 15 adj
Anthem BCBS
Profee · CIO ASC, Non-OA Indiana, OA Indiana, ASC, Hospital · 2023-01-01 → 2999-12-31
Base terms — first match wins
  1. 100% of the OAIndiana-Anthem-BCBS-Profee-Hospital fee schedule
Adjustments — all apply, in order
  1. Medicare multiple-procedure reduction — base codes 2; pays 100/50%
  2. Medicare multiple-therapy reduction (MPPR) — base codes 5; pays 100/50%
  3. Medicare multiple-endoscopy reduction
  4. mid-level provider reduction (by NUCC taxonomy)
  5. modifier 22 present → 120% 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
OAIN-Fee-Schedule-Insurance-Profee1 base · 15 adj
Aetna
Profee · CIO ASC, Non-OA Indiana, OA Indiana, ASC, Hospital · 2023-01-01 → 2999-12-31
Ambetter
Profee · CIO ASC, Non-OA Indiana, OA Indiana, ASC, Hospital · 2023-01-01 → 2999-12-31
Anthem Health Care Exchange
Profee · CIO ASC, Non-OA Indiana, OA Indiana, ASC, Hospital · 2023-01-01 → 2999-12-31
Anthem-WC
Profee · CIO ASC, Non-OA Indiana, OA Indiana, ASC, Hospital · 2023-01-01 → 2999-12-31
Ascension
Profee · CIO ASC, Non-OA Indiana, OA Indiana, ASC, Hospital · 2023-01-01 → 2999-12-31
Ball State Athletics
Profee · CIO ASC, Non-OA Indiana, OA Indiana, ASC, Hospital · 2023-01-01 → 2999-12-31
Care Source Exchange
Profee · CIO ASC, Non-OA Indiana, OA Indiana, ASC, Hospital · 2023-01-01 → 2999-12-31
Claim DOC
Profee · CIO ASC, Non-OA Indiana, OA Indiana, ASC, Hospital · 2023-01-01 → 2999-12-31
Encore Encircle
Profee · CIO ASC, Non-OA Indiana, OA Indiana, ASC, Hospital · 2023-01-01 → 2999-12-31
GPA DE
Profee · CIO ASC, Non-OA Indiana, OA Indiana, ASC, Hospital · 2023-01-01 → 2999-12-31
Humana
Profee · CIO ASC, Non-OA Indiana, OA Indiana, ASC, Hospital · 2023-01-01 → 2999-12-31
Indiana ABS
Profee · CIO ASC, Non-OA Indiana, OA Indiana, ASC, Hospital · 2023-01-01 → 2999-12-31
Indiana Medicaid
Profee · CIO ASC, Non-OA Indiana, OA Indiana, ASC, Hospital · 2023-01-01 → 2999-12-31
IU Senate Health
Profee · CIO ASC, Non-OA Indiana, OA Indiana, ASC, Hospital · 2023-01-01 → 2999-12-31
One Call Medical
Profee · CIO ASC, Non-OA Indiana, OA Indiana, ASC, Hospital · 2023-01-01 → 2999-12-31
ProHealth
Profee · CIO ASC, Non-OA Indiana, OA Indiana, ASC, Hospital · 2023-01-01 → 2999-12-31
Sagamore
Profee · CIO ASC, Non-OA Indiana, OA Indiana, ASC, Hospital · 2023-01-01 → 2999-12-31
St. Vincent Health
Profee · CIO ASC, Non-OA Indiana, OA Indiana, ASC, Hospital · 2023-01-01 → 2999-12-31
Tricare
Profee · CIO ASC, Non-OA Indiana, OA Indiana, ASC, Hospital · 2023-01-01 → 2999-12-31
Base terms — first match wins
  1. 100% of the Profee-ASC fee schedule — when FacilityType in ASC, Hospital
Adjustments — all apply, in order
  1. Medicare multiple-procedure reduction — base codes 2; pays 100/50%
  2. Medicare multiple-therapy reduction (MPPR) — base codes 5; pays 100/50%
  3. Medicare multiple-endoscopy reduction
  4. mid-level provider reduction (by NUCC taxonomy)
  5. modifier 22 present → 120% 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
OAIN-Fee-Schedule-Insurance-Profee-Clinic1 base · 15 adj
Aetna
Profee · CIO ASC, Non-OA Indiana, OA Indiana, Clinic · 2023-01-01 → 2999-12-31
Ambetter
Profee · CIO ASC, Non-OA Indiana, OA Indiana, Clinic · 2023-01-01 → 2999-12-31
Anthem Health Care Exchange
Profee · CIO ASC, Non-OA Indiana, OA Indiana, Clinic · 2023-01-01 → 2999-12-31
Anthem-WC
Profee · CIO ASC, Non-OA Indiana, OA Indiana, Clinic · 2023-01-01 → 2999-12-31
Ascension
Profee · CIO ASC, Non-OA Indiana, OA Indiana, Clinic · 2023-01-01 → 2999-12-31
Ball State Athletics
Profee · CIO ASC, Non-OA Indiana, OA Indiana, Clinic · 2023-01-01 → 2999-12-31
Care Source Exchange
Profee · CIO ASC, Non-OA Indiana, OA Indiana, Clinic · 2023-01-01 → 2999-12-31
Claim DOC
Profee · CIO ASC, Non-OA Indiana, OA Indiana, Clinic · 2023-01-01 → 2999-12-31
Encore Encircle
Profee · CIO ASC, Non-OA Indiana, OA Indiana, Clinic · 2023-01-01 → 2999-12-31
GPA DE
Profee · CIO ASC, Non-OA Indiana, OA Indiana, Clinic · 2023-01-01 → 2999-12-31
Humana
Profee · CIO ASC, Non-OA Indiana, OA Indiana, Clinic · 2023-01-01 → 2999-12-31
Indiana ABS
Profee · CIO ASC, Non-OA Indiana, OA Indiana, Clinic · 2023-01-01 → 2999-12-31
Indiana Medicaid
Profee · CIO ASC, Non-OA Indiana, OA Indiana, Clinic · 2023-01-01 → 2999-12-31
IU Senate Health
Profee · CIO ASC, Non-OA Indiana, OA Indiana, Clinic · 2023-01-01 → 2999-12-31
One Call Medical
Profee · CIO ASC, Non-OA Indiana, OA Indiana, Clinic · 2023-01-01 → 2999-12-31
ProHealth
Profee · CIO ASC, Non-OA Indiana, OA Indiana, Clinic · 2023-01-01 → 2999-12-31
Sagamore
Profee · CIO ASC, Non-OA Indiana, OA Indiana, Clinic · 2023-01-01 → 2999-12-31
St. Vincent Health
Profee · CIO ASC, Non-OA Indiana, OA Indiana, Clinic · 2023-01-01 → 2999-12-31
Tricare
Profee · CIO ASC, Non-OA Indiana, OA Indiana, Clinic · 2023-01-01 → 2999-12-31
Base terms — first match wins
  1. 100% of the Profee-Clinic fee schedule — when FacilityType in Clinic
Adjustments — all apply, in order
  1. Medicare multiple-procedure reduction — base codes 2; pays 100/50%
  2. Medicare multiple-therapy reduction (MPPR) — base codes 5; pays 100/50%
  3. Medicare multiple-endoscopy reduction
  4. mid-level provider reduction (by NUCC taxonomy)
  5. modifier 22 present → 120% 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
Ohio-Anthem-Commercial-Pre-2024-rate-changes3 base · 19 adj
Anthem
Facility · Non-OA Ohio, OA Ohio · 2023-01-01 → 2024-03-31
Base terms — first match wins
  1. 100% of the Fixed-Fees fee schedule
  2. 100% of the ASC-Grouper fee schedule
  3. 50% of billed charges
Adjustments — all apply, in order
  1. multiple-procedure reduction (contract rules) — base codes 2; pays 100/35%
  2. multiple-procedure reduction (contract rules) — base codes 2; pays 100/30%
  3. multiple-procedure reduction (contract rules) — base codes 2; pays 100/25%
  4. rescale to 85% of the running amount — when Mid-Level-Providers Mid-Level is present
  5. Medicare multiple-procedure reduction — base codes 2; pays 100/50%
  6. modifier 22 present → 120% 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 → 70% of the running amount
  10. modifier 62 present → 63% 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 → 14% of the running amount
  16. modifier 25 present → 50% of the running amount
  17. modifier 53 present → 50% of the running amount
  18. modifier 55 present → 20% of the running amount
  19. cap each charge and the account total at 100% of billed charges
Ohio-Medicaid-Profees9 base · 18 adj
Ohio Medicaid
Profee · 235 named facilities · 2018-01-01 → 2999-12-31
Base terms — first match wins
  1. 50% of Medicare anesthesia — when Modifier QX is present
  2. 50% of Medicare anesthesia — when Modifier QY is present
  3. 50% of Medicare anesthesia — when Modifier QK is present
  4. 300% of Medicare anesthesia — when Modifier AD is present
  5. 100% of Medicare anesthesia
  6. 100% of the Fixed-Fees-DME fee schedule
  7. 100% of the Fixed-Fees-Drug fee schedule
  8. 100% of the Fixed-Fees-Lab fee schedule
  9. 100% of the Profee-Fees fee schedule
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
Ohio-Workers-Comp-ASC1 base · 19 adj
Ohio Workers Comp
Facility · Non-OA Ohio, OA Ohio · 2026-05-01 → 2999-12-31
Base terms — first match wins
  1. 100% of the Ohio Work Comp-ASC fee schedule
Adjustments — all apply, in order
  1. rescale to 85% of the running amount — when Mid-Level-Providers Mid-Level is present
  2. Medicare multiple-procedure reduction — base codes 2; pays 100/50%
  3. Medicare multiple-therapy reduction (MPPR) — base codes 5; pays 100/50%
  4. custom SQL — Caps a charge's allowed amount when its billed units exceed a per-procedure maximum-allowed-units limit (a therapy/multiple-unit cap): if the code has a configured max-units value and billed Units exceed it, the allowed amount is scaled down proportionally (Allowed * maxUnits/units); otherwise Allowed passes through unchanged. — when CMS_Therapy_Codes True is present
  5. Medicare multiple-endoscopy reduction
  6. modifier 22 present → 120% 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 → 70% of the running amount
  10. modifier 62 present → 63% 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 → 14% of the running amount
  16. modifier 25 present → 50% of the running amount
  17. modifier 53 present → 50% of the running amount
  18. modifier 55 present → 20% of the running amount
  19. cap each charge and the account total at 100% of billed charges
Ohio-Workers-Comp-Profees3 base · 20 adj
Ohio Workers Comp
Profee · 419 named facilities · 2023-01-01 → 2024-12-31
Base terms — first match wins
  1. 195% of Medicare anesthesia
  2. 100% of Medicare RVU
    • CodeRange 10021–69990 → 218%
    • CodeRange 70010–79999 → 141%
    • CodeRange 80048–89399 → 125%
    • CodeRange 90281–99600 → 141%
  3. 100% of the Profee-Fees fee schedule
Adjustments — all apply, in order
  1. Medicare multiple-procedure reduction — base codes 2; pays 100/50/50/50/50/25%
  2. Medicare multiple-therapy reduction (MPPR) — base codes 5; pays 100/50%
  3. Medicare multiple-radiology reduction — base codes 4
  4. Medicare multiple-endoscopy reduction
  5. Medicare multiple-ophthalmology reduction — base codes 7; pays 100/80%
  6. mid-level provider reduction (by NUCC taxonomy)
  7. modifier 22 present → 120% of the running amount
  8. modifier 50 present → 150% of the running amount
  9. modifier 52 present → 50% of the running amount
  10. modifier 53 present → 50% of the running amount
  11. modifier 54 present → 70% of the running amount
  12. modifier 55 present → 20% of the running amount
  13. modifier 56 present → 10% of the running amount
  14. modifier 62 present → 62.5% of the running amount
  15. modifier 80 present → 20% of the running amount
  16. modifier 81 present → 10% of the running amount
  17. modifier 82 present → 20% of the running amount
  18. modifier AD present → 50% of the running amount
  19. modifier FY present → 93% of the running amount
  20. cap each charge and the account total at 100% of billed charges
Ohio-Workers-Comp-Profees-20253 base · 33 adj
Ohio Workers Comp
Profee · 235 named facilities · 2025-01-01 → 2999-12-31
Base terms — first match wins
  1. 198.61% of Medicare anesthesia
  2. 100% of Medicare RVU
    • CodeRange 10021–69990 → 221.93%
    • CodeRange 70010–79999 → 143.54%
    • CodeRange 80048–89399 → 125%
    • CodeRange 0001U–0363U → 125%
    • CodeRange 90281–99600 → 143.54%
  3. 100% of the Profee-Fees fee schedule
Adjustments — all apply, in order
  1. Medicare multiple-procedure reduction — base codes 2; pays 100/50/50/50/50/25%
  2. Medicare multiple-therapy reduction (MPPR) — base codes 5; pays 100/50%
  3. Medicare multiple-radiology reduction — base codes 4
  4. Medicare multiple-endoscopy reduction
  5. Medicare multiple-ophthalmology reduction — base codes 7; pays 100/80%
  6. mid-level provider reduction (by NUCC taxonomy)
  7. modifier 22 present → 120% of the running amount
  8. modifier 50 present → 150% of the running amount
  9. modifier 52 present → 50% of the running amount
  10. modifier 53 present → 50% of the running amount
  11. modifier 54 present → 70% of the running amount
  12. modifier 55 present → 20% of the running amount
  13. modifier 56 present → 10% of the running amount
  14. modifier 62 present → 62.5% of the running amount
  15. modifier 80 present → 20% of the running amount
  16. modifier 81 present → 10% of the running amount
  17. modifier 82 present → 20% of the running amount
  18. modifier AD present → 50% of the running amount
  19. modifier CT present → 85% of the running amount
  20. modifier FX present → 80% of the running amount
  21. modifier FY present → 93% of the running amount
  22. modifier QA present → 50% of the running amount
  23. modifier QB present → 150% of the running amount
  24. modifier QE present → 50% of the running amount
  25. modifier QF present → 150% of the running amount
  26. modifier QG present → 150% of the running amount
  27. modifier QR present → 150% of the running amount
  28. modifier QK present → 50% of the running amount
  29. modifier QX present → 50% of the running amount
  30. modifier QY present → 50% of the running amount
  31. modifier PC present → 50% of the running amount
  32. modifier SC present → 50% of the running amount
  33. cap each charge and the account total at 100% of billed charges
PHP-Northern-Indiana-Profee1 base · 18 adj
PHP Northern Indiana
Profee · 40 named facilities · 2022-07-01 → 2999-12-31
Base terms — first match wins
  1. 100% of the EncoreCombined-Fixed-Fees-SBO fee schedule
Adjustments — all apply, in order
  1. rescale to 85% of the running amount — when Mid-Level-Providers Mid-Level is present
  2. Medicare multiple-procedure reduction — base codes 2; pays 100/50%
  3. Medicare multiple-therapy reduction (MPPR) — base codes 5; pays 100/50%
  4. Medicare multiple-endoscopy reduction
  5. modifier 22 present → 120% 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. modifier 62 present → 63% 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 25 present → 50% of the running amount
  16. modifier 53 present → 50% of the running amount
  17. modifier 55 present → 20% of the running amount
  18. cap each charge and the account total at 100% of billed charges
Quality-Care-Partners-Beacon-ASC2 base · 16 adj
Quality Care Partners
Facility · 153 named facilities · 2025-12-01 → 2999-12-31
Base terms — first match wins
  1. 215% of Medicare ASC
  2. 60% of billed charges
Adjustments — all apply, in order
  1. Medicare multiple-procedure reduction — base codes 2; pays 100/50%
  2. Medicare multiple-therapy reduction (MPPR) — base codes 5; pays 100/50%
  3. rescale to 85% of the running amount — when Mid-Level-Providers Mid-Level is present
  4. modifier 22 present → 120% 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. modifier 62 present → 63% 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 25 present → 50% of the running amount
  15. modifier 53 present → 50% of the running amount
  16. modifier 55 present → 20% of the running amount
SEMMA-SBO-Profee-Clinic4 base · 15 adj
SEMMA
Profee · 40 named facilities · 2025-07-08 → 2999-12-31
Base terms — first match wins
  1. 140% of Medicare anesthesia
  2. 167% of Medicare DME
  3. 167% of Medicare RVU
  4. flat $0 — when CMS_Status_Code Noncovered is present
Adjustments — all apply, in order
  1. Medicare multiple-procedure reduction — base codes 2; pays 100/50%
  2. Medicare multiple-therapy reduction (MPPR) — base codes 5; pays 100/50%
  3. Medicare multiple-endoscopy reduction
  4. mid-level provider reduction (by NUCC taxonomy)
  5. modifier 22 present → 120% 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
Self-Pay-Facility2 base · 1 adj
Self-Pay
Facility · 405 named facilities · 2016-01-01 → 2999-12-31
Base terms — first match wins
  1. 100% of the BundleCharges fee schedule
  2. 70% of the ChargeMaster-ASC fee schedule
Adjustments — all apply, in order
  1. multiple-procedure reduction (contract rules) — base codes 2; pays 100/50%
Self-Pay-Profee-Clinic1 base · 0 adj
Self-Pay
Profee · 188 named facilities · 2016-01-01 → 2999-12-31
Base terms — first match wins
  1. 70% of the ChargeMaster-Profee fee schedule
Self-Pay-Profee-Hospital1 base · 1 adj
Self-Pay
Profee · 129 named facilities · 2016-01-01 → 2999-12-31
Base terms — first match wins
  1. 70% of the ChargeMaster-Profee fee schedule
Adjustments — all apply, in order
  1. multiple-procedure reduction (contract rules) — base codes 2; pays 100/50%
Self-Pay-Profee-SBO1 base · 1 adj
Self-Pay
Profee · 69 named facilities · 2022-01-01 → 2999-12-31
Base terms — first match wins
  1. 80% of the ChargeMaster-Profee fee schedule
Adjustments — all apply, in order
  1. multiple-procedure reduction (contract rules) — base codes 2; pays 100/62.5%
Signature-Care-Profee1 base · 18 adj
Signature Care
Profee · 40 named facilities · 2022-07-01 → 2999-12-31
Base terms — first match wins
  1. 100% of the EncoreCombined-Fixed-Fees-SBO fee schedule
Adjustments — all apply, in order
  1. rescale to 85% of the running amount — when Mid-Level-Providers Mid-Level is present
  2. Medicare multiple-procedure reduction — base codes 2; pays 100/50%
  3. Medicare multiple-therapy reduction (MPPR) — base codes 5; pays 100/50%
  4. Medicare multiple-endoscopy reduction
  5. modifier 22 present → 120% 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. modifier 62 present → 63% 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 25 present → 50% of the running amount
  16. modifier 53 present → 50% of the running amount
  17. modifier 55 present → 20% of the running amount
  18. cap each charge and the account total at 100% of billed charges
United-Healthcare-ASC14 base · 19 adj
United Healthcare
Facility · Non-OA Ohio, OA JV, OA Ohio, Other · 2023-03-01 → 2025-02-28
Base terms — first match wins
  1. 100% of billed charges — when ProcedureCode C1713 is present; RevenueCode 274 is present
  2. 100% of billed charges — when ProcedureCode C1713 is present; RevenueCode 275 is present
  3. 100% of billed charges — when ProcedureCode C1713 is present; RevenueCode 276 is present
  4. 100% of billed charges — when ProcedureCode C1713 is present; RevenueCode 278 is present
  5. case rate from Fixed-Fees-Case-Rate (All-level codes) — when RevenueCode 360 is present
  6. case rate from Fixed-Fees-Case-Rate (All-level codes) — when RevenueCode 361 is present
  7. case rate from Fixed-Fees-Case-Rate (All-level codes) — when RevenueCode 369 is present
  8. case rate from Fixed-Fees-Case-Rate (All-level codes) — when RevenueCode 481 is present
  9. case rate from Fixed-Fees-Case-Rate (All-level codes) — when RevenueCode 490 is present
  10. case rate from Fixed-Fees-Case-Rate (All-level codes) — when RevenueCode 499 is present
  11. case rate from Fixed-Fees-Case-Rate (All-level codes) — when RevenueCode 750 is present
  12. case rate from Fixed-Fees-Case-Rate (All-level codes) — when RevenueCode 790 is present
  13. 100% of the Fixed-Fees fee schedule
  14. 100% of the ASC-Grouper fee schedule
Adjustments — all apply, in order
  1. multiple-surgery reduction (contract rules) — pays 100/50/25/0%
  2. custom SQL — Caps a charge's allowed amount when its billed units exceed a per-procedure maximum-allowed-units limit (a therapy/multiple-unit cap): if the code has a configured max-units value and billed Units exceed it, the allowed amount is scaled down proportionally (Allowed * maxUnits/units); otherwise Allowed passes through unchanged. — when CMS_Therapy_Codes True is present
  3. rescale to 85% of the running amount — when Mid-Level-Providers Mid-Level is present
  4. Medicare multiple-endoscopy reduction
  5. modifier 22 present → 120% 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. modifier 62 present → 63% 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 25 present → 50% of the running amount
  16. modifier 53 present → 50% of the running amount
  17. modifier 55 present → 20% of the running amount
  18. cap each charge and the account total at 100% of billed charges
  19. custom SQL — Caps the allowed amount at $7,000 for HCPCS C1713 (a device/implant pass-through code), otherwise leaves the already-computed Allowed amount unchanged. — when ProcedureCode C1713 is present
United-Healthcare-ASC-202513 base · 19 adj
United Healthcare
Facility · Non-OA Ohio, OA JV, OA Ohio, Other · 2025-03-01 → 2026-02-28
Base terms — first match wins
  1. 100% of billed charges — when ProcedureCode C1713 is present; RevenueCode 274 is present
  2. 100% of billed charges — when ProcedureCode C1713 is present; RevenueCode 275 is present
  3. 100% of billed charges — when ProcedureCode C1713 is present; RevenueCode 276 is present
  4. 100% of billed charges — when ProcedureCode C1713 is present; RevenueCode 278 is present
  5. case rate from Fixed-Fees-Case-Rate (All-level codes) — when RevenueCode 360 is present
  6. case rate from Fixed-Fees-Case-Rate (All-level codes) — when RevenueCode 361 is present
  7. case rate from Fixed-Fees-Case-Rate (All-level codes) — when RevenueCode 369 is present
  8. case rate from Fixed-Fees-Case-Rate (All-level codes) — when RevenueCode 481 is present
  9. case rate from Fixed-Fees-Case-Rate (All-level codes) — when RevenueCode 490 is present
  10. case rate from Fixed-Fees-Case-Rate (All-level codes) — when RevenueCode 499 is present
  11. case rate from Fixed-Fees-Case-Rate (All-level codes) — when RevenueCode 750 is present
  12. case rate from Fixed-Fees-Case-Rate (All-level codes) — when RevenueCode 790 is present
  13. 100% of the ASC-Grouper fee schedule
Adjustments — all apply, in order
  1. multiple-surgery reduction (contract rules) — pays 100/50/25/0%
  2. custom SQL — Caps a charge's allowed amount when its billed units exceed a per-procedure maximum-allowed-units limit (a therapy/multiple-unit cap): if the code has a configured max-units value and billed Units exceed it, the allowed amount is scaled down proportionally (Allowed * maxUnits/units); otherwise Allowed passes through unchanged. — when CMS_Therapy_Codes True is present
  3. rescale to 85% of the running amount — when Mid-Level-Providers Mid-Level is present
  4. Medicare multiple-endoscopy reduction
  5. modifier 22 present → 120% 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. modifier 62 present → 63% 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 25 present → 50% of the running amount
  16. modifier 53 present → 50% of the running amount
  17. modifier 55 present → 20% of the running amount
  18. cap each charge and the account total at 100% of billed charges
  19. custom SQL — Caps the allowed amount at $7,000 for HCPCS C1713 (a device/implant pass-through code), otherwise leaves the already-computed Allowed amount unchanged. — when ProcedureCode C1713 is present
United-Healthcare-Clinic-OH-2022-086 base · 19 adj
United Healthcare
Profee · Beacon ASC, Non-OA Ohio, OA JV, OA Ohio · 2022-08-01 → 2023-07-31
Base terms — first match wins
  1. 100% of the Profee-Clinic fee schedule
  2. 60% of Medicare DME (rates as of 2020-01-01)
  3. 100% of Medicare drug
  4. 100% of Medicare lab
  5. 100% of Medicare RVU (rates as of 2020-01-01)
    • CodeRange 10000–69999 → 194%
    • CodeRange 70540–70559 → 245%
    • CodeRange 71550–71555 → 245%
    • CodeRange 72141–72159 → 245%
    • CodeRange 72195–72198 → 245%
    • CodeRange 70000–79999 → 130%
    • CodeRange 80000–89999 → 100%
    • CodeRange 99200–99499 → 167%
    • CodeRange 98940–98943 → 100%
    • CodeRange 97010–97799 → 100%
    • CodeRange 90000–99999 → 194%
  6. 20% of billed charges
Adjustments — all apply, in order
  1. rescale to 85% of the running amount — when Mid-Level-Providers Mid-Level is present
  2. Medicare multiple-procedure reduction — base codes 2; pays 100/50%
  3. Medicare multiple-therapy reduction (MPPR) — base codes 5; pays 100/50%
  4. custom SQL — Caps a charge's allowed amount when its billed units exceed a per-procedure maximum-allowed-units limit (a therapy/multiple-unit cap): if the code has a configured max-units value and billed Units exceed it, the allowed amount is scaled down proportionally (Allowed * maxUnits/units); otherwise Allowed passes through unchanged. — when CMS_Therapy_Codes True is present
  5. Medicare multiple-endoscopy reduction
  6. modifier 22 present → 120% 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 → 70% of the running amount
  10. modifier 62 present → 63% 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 → 14% of the running amount
  16. modifier 25 present → 50% of the running amount
  17. modifier 53 present → 50% of the running amount
  18. modifier 55 present → 20% of the running amount
  19. cap each charge and the account total at 100% of billed charges
United-Healthcare-Clinic-OH-2023-087 base · 19 adj
United Healthcare
Profee · Beacon ASC, Non-OA Ohio, OA JV, OA Ohio · 2023-08-01 → 2024-07-31
Base terms — first match wins
  1. 100% of the Carveout-Fees fee schedule — when ProcedureCode 26055 is present; FacilityType Clinic is present
  2. 100% of the Carveout-Fees fee schedule — when ProcedureCode 26055 is absent
  3. 60% of Medicare DME (rates as of 2020-01-01)
  4. 100% of Medicare drug
  5. 100% of Medicare lab
  6. 100% of Medicare RVU (rates as of 2020-01-01)
    • CodeRange 10000–69999 → 198%
    • CodeRange 70540–70559 → 245%
    • CodeRange 71550–71555 → 245%
    • CodeRange 72141–72159 → 245%
    • CodeRange 72195–72198 → 245%
    • CodeRange 73218–73225 → 245%
    • CodeRange 73718–73725 → 245%
    • CodeRange 74181–74183 → 245%
    • CodeRange 70000–79999 → 130%
    • CodeRange 80000–89999 → 100%
    • CodeRange 99200–99499 → 171%
    • CodeRange 98940–98943 → 100%
    • CodeRange 97010–97799 → 100%
    • CodeRange 90000–99999 → 198%
  7. 20% of billed charges
Adjustments — all apply, in order
  1. rescale to 85% of the running amount — when Mid-Level-Providers Mid-Level is present
  2. Medicare multiple-procedure reduction — base codes 2; pays 100/50%
  3. Medicare multiple-therapy reduction (MPPR) — base codes 5; pays 100/50%
  4. custom SQL — Caps a charge's allowed amount when its billed units exceed a per-procedure maximum-allowed-units limit (a therapy/multiple-unit cap): if the code has a configured max-units value and billed Units exceed it, the allowed amount is scaled down proportionally (Allowed * maxUnits/units); otherwise Allowed passes through unchanged. — when CMS_Therapy_Codes True is present
  5. Medicare multiple-endoscopy reduction
  6. modifier 22 present → 120% 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 → 70% of the running amount
  10. modifier 62 present → 63% 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 → 14% of the running amount
  16. modifier 25 present → 50% of the running amount
  17. modifier 53 present → 50% of the running amount
  18. modifier 55 present → 20% of the running amount
  19. cap each charge and the account total at 100% of billed charges
United-Healthcare-Clinic-OH-2024-087 base · 20 adj
United Healthcare
Profee · Beacon ASC, Non-OA Ohio, OA JV, OA Ohio · 2024-08-01 → 2026-07-31
Base terms — first match wins
  1. 100% of the Carveout-Fees fee schedule — when ProcedureCode 26055 is present; FacilityType Clinic is present
  2. 100% of the Carveout-Fees fee schedule — when ProcedureCode 26055 is absent
  3. 60% of Medicare DME (rates as of 2020-01-01)
  4. 100% of Medicare drug
  5. 100% of Medicare lab
  6. 100% of Medicare RVU (rates as of 2020-01-01)
    • CodeRange 10000–69999 → 202%
    • CodeRange 70540–70559 → 245%
    • CodeRange 71550–71555 → 245%
    • CodeRange 72141–72159 → 245%
    • CodeRange 72195–72198 → 245%
    • CodeRange 73218–73225 → 245%
    • CodeRange 73718–73725 → 245%
    • CodeRange 74181–74183 → 245%
    • CodeRange 70000–79999 → 130%
    • CodeRange 80000–89999 → 100%
    • CodeRange 99200–99499 → 174%
    • CodeRange 98940–98943 → 100%
    • CodeRange 97010–97799 → 100%
    • CodeRange 90000–99999 → 198%
  7. 20% of billed charges
Adjustments — all apply, in order
  1. rescale to 85% of the running amount — when Mid-Level-Providers Mid-Level is present
  2. Medicare multiple-procedure reduction — base codes 2; pays 100/50%
  3. Medicare multiple-therapy reduction (MPPR) — base codes 5; pays 100/50%
  4. custom SQL — Caps a charge's allowed amount when its billed units exceed a per-procedure maximum-allowed-units limit (a therapy/multiple-unit cap): if the code has a configured max-units value and billed Units exceed it, the allowed amount is scaled down proportionally (Allowed * maxUnits/units); otherwise Allowed passes through unchanged. — when CMS_Therapy_Codes True is present
  5. Medicare multiple-endoscopy reduction
  6. modifier 22 present → 120% 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 → 70% of the running amount
  10. modifier 62 present → 63% 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 → 14% of the running amount
  16. modifier 25 present → 50% of the running amount
  17. modifier 53 present → 50% of the running amount
  18. modifier 55 present → 20% of the running amount
  19. modifier QZ present → 85% of the running amount
  20. cap each charge and the account total at 100% of billed charges
United-Healthcare-IN-Clinic12 base · 19 adj
United Healthcare
Profee · CIO ASC, Non-OA Indiana, OA Indiana · 2022-08-01 → 2023-07-31
Base terms — first match wins
  1. 100% of the Profee-Clinic fee schedule
  2. 60% of Medicare DME (rates as of 2020-01-01)
  3. computed expression (operands follow)
  4. 100% of Medicare RVU (rates as of 2020-01-01)
  5. Multiply 100% of the Fixed-Fees-Profee fee schedule
  6. computed expression (operands follow)
  7. 100% of Medicare drug
  8. Multiply 100% of the Fixed-Fees-Profee fee schedule
  9. computed expression (operands follow)
  10. 100% of Medicare lab
  11. Multiply 100% of the Fixed-Fees-Profee fee schedule
  12. 20% of billed charges
Adjustments — all apply, in order
  1. rescale to 85% of the running amount — when Mid-Level-Providers Mid-Level is present
  2. Medicare multiple-procedure reduction — base codes 2; pays 100/50%
  3. Medicare multiple-therapy reduction (MPPR) — base codes 5; pays 100/50%
  4. custom SQL — Caps a charge's allowed amount when its billed units exceed a per-procedure maximum-allowed-units limit (a therapy/multiple-unit cap): if the code has a configured max-units value and billed Units exceed it, the allowed amount is scaled down proportionally (Allowed * maxUnits/units); otherwise Allowed passes through unchanged. — when CMS_Therapy_Codes True is present
  5. Medicare multiple-endoscopy reduction
  6. modifier 22 present → 120% 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 → 70% of the running amount
  10. modifier 62 present → 63% 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 → 14% of the running amount
  16. modifier 25 present → 50% of the running amount
  17. modifier 53 present → 50% of the running amount
  18. modifier 55 present → 20% of the running amount
  19. cap each charge and the account total at 100% of billed charges
United-Healthcare-IN-Clinic-202312 base · 19 adj
United Healthcare
Profee · CIO ASC, Non-OA Indiana, OA Indiana · 2023-08-01 → 2024-07-31
Base terms — first match wins
  1. 100% of the Profee-Clinic fee schedule
  2. 60% of Medicare DME (rates as of 2020-01-01)
  3. computed expression (operands follow)
  4. 100% of Medicare RVU (rates as of 2020-01-01)
  5. Multiply 100% of the Fixed-Fees-Profee fee schedule
  6. computed expression (operands follow)
  7. 100% of Medicare drug
  8. Multiply 100% of the Fixed-Fees-Profee fee schedule
  9. computed expression (operands follow)
  10. 100% of Medicare lab
  11. Multiply 100% of the Fixed-Fees-Profee fee schedule
  12. 20% of billed charges
Adjustments — all apply, in order
  1. rescale to 85% of the running amount — when Mid-Level-Providers Mid-Level is present
  2. Medicare multiple-procedure reduction — base codes 2; pays 100/50%
  3. Medicare multiple-therapy reduction (MPPR) — base codes 5; pays 100/50%
  4. custom SQL — Caps a charge's allowed amount when its billed units exceed a per-procedure maximum-allowed-units limit (a therapy/multiple-unit cap): if the code has a configured max-units value and billed Units exceed it, the allowed amount is scaled down proportionally (Allowed * maxUnits/units); otherwise Allowed passes through unchanged. — when CMS_Therapy_Codes True is present
  5. Medicare multiple-endoscopy reduction
  6. modifier 22 present → 120% 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 → 70% of the running amount
  10. modifier 62 present → 63% 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 → 14% of the running amount
  16. modifier 25 present → 50% of the running amount
  17. modifier 53 present → 50% of the running amount
  18. modifier 55 present → 20% of the running amount
  19. cap each charge and the account total at 100% of billed charges
United-Healthcare-IN-Clinic-202410 base · 19 adj
United Healthcare
Profee · CIO ASC, Non-OA Indiana, OA Indiana · 2024-08-01 → 2999-12-31
Base terms — first match wins
  1. 100% of the Profee-Clinic fee schedule
  2. 60% of Medicare DME (rates as of 2020-01-01)
  3. 100% of Medicare RVU (rates as of 2020-01-01)
    • CodeRange 10000–69999 → 198%
    • CodeRange 70540–70559 → 245%
    • CodeRange 71550–71555 → 245%
    • CodeRange 72141–72159 → 245%
    • CodeRange 72195–72198 → 245%
    • CodeRange 73218–73225 → 245%
    • CodeRange 73718–73725 → 245%
    • CodeRange 74181–74183 → 245%
    • CodeRange 70000–79999 → 130%
    • CodeRange 80000–89999 → 100%
    • CodeRange 99200–99499 → 171%
    • CodeRange 98940–98943 → 100%
    • CodeRange 97010–97799 → 100%
    • CodeRange 90000–99999 → 198%
  4. computed expression (operands follow)
  5. 100% of Medicare drug
  6. Multiply 100% of the Fixed-Fees-Profee fee schedule
  7. computed expression (operands follow)
  8. 100% of Medicare lab
  9. Multiply 100% of the Fixed-Fees-Profee fee schedule
  10. 20% of billed charges
Adjustments — all apply, in order
  1. rescale to 85% of the running amount — when Mid-Level-Providers Mid-Level is present
  2. Medicare multiple-procedure reduction — base codes 2; pays 100/50%
  3. custom SQL — Caps a charge's allowed amount when its billed units exceed a per-procedure maximum-allowed-units limit (a therapy/multiple-unit cap): if the code has a configured max-units value and billed Units exceed it, the allowed amount is scaled down proportionally (Allowed * maxUnits/units); otherwise Allowed passes through unchanged. — when CMS_Therapy_Codes True is present
  4. Medicare multiple-endoscopy reduction
  5. modifier 22 present → 120% 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. modifier 62 present → 63% 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 25 present → 50% of the running amount
  16. modifier 53 present → 50% of the running amount
  17. modifier 55 present → 20% of the running amount
  18. modifier QZ present → 85% of the running amount
  19. 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-Profee-Clinic · no contract map5 base · 18 adj
no contract map — cannot be resolved
Base terms — first match wins
  1. computed expression (operands follow)
  2. 100% of the Profee-Clinic fee schedule
  3. Multiply 100% of the Fixed-Fees-Percentage fee schedule
  4. 100% of the Profee-Clinic fee schedule
  5. 60% of billed charges
Adjustments — all apply, in order
  1. rescale to 85% of the running amount — when Mid-Level-Providers Mid-Level is present
  2. Medicare multiple-procedure reduction — base codes 2; pays 100/50%
  3. Medicare multiple-therapy reduction (MPPR) — base codes 5; pays 100/50%
  4. Medicare multiple-endoscopy reduction
  5. modifier 22 present → 120% 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. modifier 62 present → 63% 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 25 present → 50% of the running amount
  16. modifier 53 present → 50% of the running amount
  17. modifier 55 present → 20% of the running amount
  18. cap each charge and the account total at 100% of billed charges
Aetna-Profee-Hospital · no contract map5 base · 18 adj
no contract map — cannot be resolved
Base terms — first match wins
  1. computed expression (operands follow)
  2. 100% of the Profee-Hospital fee schedule
  3. Multiply 100% of the Fixed-Fees-Percentage fee schedule
  4. 100% of the Profee-Hospital fee schedule
  5. 60% of billed charges
Adjustments — all apply, in order
  1. rescale to 85% of the running amount — when Mid-Level-Providers Mid-Level is present
  2. Medicare multiple-procedure reduction — base codes 2; pays 100/50%
  3. Medicare multiple-therapy reduction (MPPR) — base codes 5; pays 100/50%
  4. Medicare multiple-endoscopy reduction
  5. modifier 22 present → 120% 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. modifier 62 present → 63% 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 25 present → 50% of the running amount
  16. modifier 53 present → 50% of the running amount
  17. modifier 55 present → 20% of the running amount
  18. cap each charge and the account total at 100% of billed charges
Anthem-Ohio-Profees-2024-to-2026 · no contract map12 base · 17 adj
no contract map — cannot be resolved
Base terms — first match wins
  1. 100% of the Therapist-Profee fee schedule — when ProviderType Respiratory Therapist, Certified is present
  2. 100% of the Therapist-Profee fee schedule — when ProviderType Physical Therapist is present
  3. 100% of the Podiatrist-Profees fee schedule — when ProviderType Podiatrist is present
  4. 100% of the Fixed-Fees-Podiatry fee schedule — when ProviderType Podiatrist is present
  5. 100% of the Profee-Fees fee schedule — when ProviderType Podiatrist is absent
  6. 100% of the Fixed-Fees-DME fee schedule — when ProviderType Podiatrist is absent
  7. 100% of Medicare drug
  8. 111.2% of Medicare DME
  9. 111.2% of Medicare lab
  10. 111.2% of Medicare RVU
  11. flat $0 — when UnlistedProceduresCPT True is present
  12. flat $0 — when CMS_Status_Code Noncovered is present
Adjustments — all apply, in order
  1. mid-level provider reduction (by NUCC taxonomy)
  2. Medicare multiple-procedure reduction — base codes 2; pays 100/50/25/0%
  3. Medicare multiple-endoscopy reduction
  4. modifier 22 present → 120% 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. modifier 62 present → 63% 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 25 present → 50% of the running amount
  15. modifier 53 present → 50% of the running amount
  16. modifier 55 present → 20% of the running amount
  17. cap each charge and the account total at 100% of billed charges
Anthem-Ohio-Profees-2024-to-2026 · no contract map12 base · 17 adj
no contract map — cannot be resolved
Base terms — first match wins
  1. 100% of the Therapist-Profee fee schedule — when ProviderType Respiratory Therapist, Certified is present
  2. 100% of the Therapist-Profee fee schedule — when ProviderType Physical Therapist is present
  3. 100% of the Podiatrist-Profees fee schedule — when ProviderType Podiatrist is present
  4. 100% of the Fixed-Fees-Podiatry fee schedule — when ProviderType Podiatrist is present
  5. 100% of the Profee-Fees fee schedule — when ProviderType Podiatrist is absent
  6. 100% of the Fixed-Fees-DME fee schedule — when ProviderType Podiatrist is absent
  7. 100% of Medicare drug
  8. 113.61% of Medicare DME ⚠︎ named “111.2% Medicare Lab Fallback” but configured at 113.61%
  9. 113.61% of Medicare lab ⚠︎ named “111.2% Medicare DME Fallback” but configured at 113.61%
  10. 113.61% of Medicare RVU ⚠︎ named “111.2% Medicare RVU Fallback” but configured at 113.61%
  11. flat $0 — when UnlistedProceduresCPT True is present
  12. flat $0 — when CMS_Status_Code Noncovered is present
Adjustments — all apply, in order
  1. mid-level provider reduction (by NUCC taxonomy)
  2. Medicare multiple-procedure reduction — base codes 2; pays 100/50/25/0%
  3. Medicare multiple-endoscopy reduction
  4. modifier 22 present → 120% 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. modifier 62 present → 63% 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 25 present → 50% of the running amount
  15. modifier 53 present → 50% of the running amount
  16. modifier 55 present → 20% of the running amount
  17. cap each charge and the account total at 100% of billed charges
Anthem-Profee-ASC · no contract map10 base · 20 adj
no contract map — cannot be resolved
Base terms — first match wins
  1. 100% of the Fixed-Fees-Podiatrist-Hospital fee schedule — when ProviderType Podiatrist is present
  2. 100% of the Carveout-Fees-ASC fee schedule
  3. 100% of the Fixed-Fees-PT fee schedule — when ProviderType Physical Medicine & Rehabilitation is present
  4. 100% of the Fixed-Fees-PT fee schedule — when ProviderType Physical Therapist is present
  5. 100% of the Fixed-Fees-DME fee schedule
  6. 100% of the Fixed-Fees-Drug fee schedule
  7. 108% of Medicare RVU
  8. flat $0 — when ProcedureCode 20930 is present
  9. flat $0 — when ProcedureCode 20936 is present
  10. flat $0 — when ProcedureCode 17999 is present
Adjustments — all apply, in order
  1. multiple-procedure reduction (contract rules) — base codes 2; pays 100/35%
  2. multiple-procedure reduction (contract rules) — base codes 2; pays 100/30%
  3. multiple-procedure reduction (contract rules) — base codes 2; pays 100/25%
  4. rescale to 85% of the running amount — when Mid-Level-Providers Mid-Level is present
  5. Medicare multiple-procedure reduction — base codes 2, 3; pays 100/50%
  6. Medicare multiple-endoscopy reduction
  7. modifier 22 present → 120% 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 → 70% of the running amount
  11. modifier 62 present → 63% 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 → 14% of the running amount
  17. modifier 25 present → 50% of the running amount
  18. modifier 53 present → 50% of the running amount
  19. modifier 55 present → 20% of the running amount
  20. cap each charge and the account total at 100% of billed charges
Anthem-Profee-Clinic · no contract map10 base · 17 adj
no contract map — cannot be resolved
Base terms — first match wins
  1. 100% of the Fixed-Fees-Podiatrist-Clinic fee schedule — when ProviderType Podiatrist is present
  2. 100% of the Carveout-Fees fee schedule
  3. 100% of the Fixed-Fees-PT fee schedule — when ProviderType Physical Medicine & Rehabilitation is present
  4. 100% of the Fixed-Fees-PT fee schedule — when ProviderType Physical Therapist is present
  5. 100% of the Fixed-Fees-DME fee schedule
  6. 100% of the Fixed-Fees-Drug fee schedule
  7. 108% of Medicare RVU
  8. flat $0 — when ProcedureCode 20930 is present
  9. flat $0 — when ProcedureCode 20936 is present
  10. flat $0 — when ProcedureCode 17999 is present
Adjustments — all apply, in order
  1. rescale to 85% of the running amount — when Mid-Level-Providers Mid-Level is present
  2. Medicare multiple-procedure reduction — base codes 2; pays 100/50%
  3. Medicare multiple-endoscopy reduction
  4. modifier 22 present → 120% 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. modifier 62 present → 63% 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 25 present → 50% of the running amount
  15. modifier 53 present → 50% of the running amount
  16. modifier 55 present → 20% of the running amount
  17. cap each charge and the account total at 100% of billed charges
Anthem-Profee-Clinic-Backup · no contract map7 base · 18 adj
no contract map — cannot be resolved
Base terms — first match wins
  1. 100% of the Fixed-Fees-Podiatrist-Clinic fee schedule — when ProviderType Podiatrist is present
  2. 100% of the Carveout-Fees fee schedule
  3. 100% of the Fixed-Fees-PT fee schedule — when ProviderType Physical Medicine & Rehabilitation is present
  4. 100% of the Fixed-Fees-PT fee schedule — when ProviderType Physical Therapist is present
  5. 100% of the Fixed-Fees-DME fee schedule
  6. 100% of the Fixed-Fees-Drug fee schedule
  7. 108% of Medicare RVU
Adjustments — all apply, in order
  1. rescale to 85% of the running amount — when Mid-Level-Providers Mid-Level is present
  2. Medicare multiple-procedure reduction — base codes 2; pays 100/50%
  3. Medicare multiple-therapy reduction (MPPR) — base codes 5; pays 100/50%
  4. Medicare multiple-endoscopy reduction
  5. modifier 22 present → 120% 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. modifier 62 present → 63% 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 25 present → 50% of the running amount
  16. modifier 53 present → 50% of the running amount
  17. modifier 55 present → 20% of the running amount
  18. cap each charge and the account total at 100% of billed charges
Anthem-Profee-Clinic_bak · no contract map10 base · 17 adj
no contract map — cannot be resolved
Base terms — first match wins
  1. 100% of the Fixed-Fees-Podiatrist-Clinic fee schedule — when ProviderType Podiatrist is present
  2. 100% of the Carveout-Fees fee schedule
  3. 100% of the Fixed-Fees-PT fee schedule — when ProviderType Physical Medicine & Rehabilitation is present
  4. 100% of the Fixed-Fees-PT fee schedule — when ProviderType Physical Therapist is present
  5. 100% of the Fixed-Fees-DME fee schedule
  6. 100% of the Fixed-Fees-Drug fee schedule
  7. 108% of Medicare RVU
  8. flat $0 — when ProcedureCode 20930 is present
  9. flat $0 — when ProcedureCode 20936 is present
  10. flat $0 — when ProcedureCode 17999 is present
Adjustments — all apply, in order
  1. rescale to 85% of the running amount — when Mid-Level-Providers Mid-Level is present
  2. Medicare multiple-procedure reduction — base codes 2; pays 100/50%
  3. Medicare multiple-endoscopy reduction
  4. modifier 22 present → 120% 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. modifier 62 present → 63% 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 25 present → 50% of the running amount
  15. modifier 53 present → 50% of the running amount
  16. modifier 55 present → 20% of the running amount
  17. cap each charge and the account total at 100% of billed charges
Charges-Facility · no contract map1 base · 0 adj
no contract map — cannot be resolved
Base terms — first match wins
  1. 100% of the ChargeMaster-ASC fee schedule
Charges-Profee · no contract map1 base · 0 adj
no contract map — cannot be resolved
Base terms — first match wins
  1. 100% of the ChargeMaster-Profee fee schedule
Cigna-Ohio-Profee-Clinic · no contract map5 base · 19 adj
no contract map — cannot be resolved
Base terms — first match wins
  1. computed expression (operands follow)
  2. 100% of the Profee-Clinic fee schedule
  3. Multiply 100% of the Fixed-Fees-Percentage fee schedule
  4. 100% of the Fixed-Fees-Carveout fee schedule
  5. 50% of billed charges
Adjustments — all apply, in order
  1. rescale to 85% of the running amount — when Mid-Level-Providers Mid-Level is present
  2. Medicare multiple-procedure reduction — base codes 2; pays 100/50%
  3. Medicare multiple-therapy reduction (MPPR) — base codes 5; pays 100/50%
  4. custom SQL — Caps a charge's allowed amount when its billed units exceed a per-procedure maximum-allowed-units limit (a therapy/multiple-unit cap): if the code has a configured max-units value and billed Units exceed it, the allowed amount is scaled down proportionally (Allowed * maxUnits/units); otherwise Allowed passes through unchanged. — when CMS_Therapy_Codes True is present
  5. Medicare multiple-endoscopy reduction
  6. modifier 22 present → 120% 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 → 70% of the running amount
  10. modifier 62 present → 63% 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 → 14% of the running amount
  16. modifier 25 present → 50% of the running amount
  17. modifier 53 present → 50% of the running amount
  18. modifier 55 present → 20% of the running amount
  19. cap each charge and the account total at 100% of billed charges
MMO-Profee-Clinic-Backup · no contract map7 base · 17 adj
no contract map — cannot be resolved
Base terms — first match wins
  1. computed expression (operands follow)
  2. 112% of Medicare RVU (rates as of 2006-01-01)
  3. Multiply 100% of the Profee-MedicareRates fee schedule
  4. 100% of the Profee-Clinic fee schedule
  5. flat $0 — when ProcedureCode 20930 is present
  6. flat $0 — when ProcedureCode 20936 is present
  7. flat $0 — when ProcedureCode 17999 is present
Adjustments — all apply, in order
  1. Medicare multiple-procedure reduction — base codes 2; pays 100/50%
  2. Medicare multiple-therapy reduction (MPPR) — base codes 5; pays 100/50%
  3. rescale to 85% of the running amount — when Mid-Level-Providers Mid-Level is present
  4. modifier 22 present → 120% 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. modifier 62 present → 63% 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 25 present → 50% of the running amount
  15. modifier 53 present → 50% of the running amount
  16. modifier 55 present → 20% of the running amount
  17. cap each charge and the account total at 100% of billed charges
MMO-Profee-Clinic-OH-OA-Backup · no contract map8 base · 17 adj
no contract map — cannot be resolved
Base terms — first match wins
  1. 100% of Medicare drug
  2. computed expression (operands follow)
  3. 112% of Medicare RVU (rates as of 2006-01-01)
  4. Multiply 100% of the Profee-MedicareRates fee schedule
  5. 100% of the Profee-Clinic fee schedule
  6. flat $0 — when ProcedureCode 20930 is present
  7. flat $0 — when ProcedureCode 20936 is present
  8. flat $0 — when ProcedureCode 17999 is present
Adjustments — all apply, in order
  1. Medicare multiple-procedure reduction — base codes 2; pays 100/50%
  2. Medicare multiple-therapy reduction (MPPR) — base codes 5; pays 100/50%
  3. rescale to 85% of the running amount — when Mid-Level-Providers Mid-Level is present
  4. modifier 22 present → 120% 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. modifier 62 present → 63% 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 25 present → 50% of the running amount
  15. modifier 53 present → 50% of the running amount
  16. modifier 55 present → 20% of the running amount
  17. cap each charge and the account total at 100% of billed charges
MMO-Profee-Facility-Backup · no contract map7 base · 17 adj
no contract map — cannot be resolved
Base terms — first match wins
  1. computed expression (operands follow)
  2. 112% of Medicare RVU (rates as of 2006-01-01)
  3. Multiply 100% of the Profee-MedicareRates fee schedule
  4. 100% of the Profee-Hospital fee schedule
  5. flat $0 — when ProcedureCode 20930 is present
  6. flat $0 — when ProcedureCode 20936 is present
  7. flat $0 — when ProcedureCode 17999 is present
Adjustments — all apply, in order
  1. Medicare multiple-procedure reduction — base codes 2; pays 100/50%
  2. Medicare multiple-therapy reduction (MPPR) — base codes 5; pays 100/50%
  3. rescale to 85% of the running amount — when Mid-Level-Providers Mid-Level is present
  4. modifier 22 present → 120% 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. modifier 62 present → 63% 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 25 present → 50% of the running amount
  15. modifier 53 present → 50% of the running amount
  16. modifier 55 present → 20% of the running amount
  17. cap each charge and the account total at 100% of billed charges
MMO-Profee-Facility-OH-OA-Backup · no contract map8 base · 17 adj
no contract map — cannot be resolved
Base terms — first match wins
  1. 100% of Medicare drug
  2. computed expression (operands follow)
  3. 112% of Medicare RVU (rates as of 2006-01-01)
  4. Multiply 100% of the Profee-MedicareRates fee schedule
  5. 100% of the Profee-Hospital fee schedule
  6. flat $0 — when ProcedureCode 20930 is present
  7. flat $0 — when ProcedureCode 20936 is present
  8. flat $0 — when ProcedureCode 17999 is present
Adjustments — all apply, in order
  1. Medicare multiple-procedure reduction — base codes 2; pays 100/50%
  2. Medicare multiple-therapy reduction (MPPR) — base codes 5; pays 100/50%
  3. rescale to 85% of the running amount — when Mid-Level-Providers Mid-Level is present
  4. modifier 22 present → 120% 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. modifier 62 present → 63% 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 25 present → 50% of the running amount
  15. modifier 53 present → 50% of the running amount
  16. modifier 55 present → 20% of the running amount
  17. cap each charge and the account total at 100% of billed charges
OAIN-Fee-Schedule-Insurance-ASC · no contract map1 base · 15 adj
no contract map — cannot be resolved
Base terms — first match wins
  1. 100% of the Facility-Fees fee schedule
Adjustments — all apply, in order
  1. Medicare multiple-procedure reduction — base codes 2; pays 100/50%
  2. Medicare multiple-therapy reduction (MPPR) — base codes 5; pays 100/50%
  3. Medicare multiple-endoscopy reduction
  4. rescale to 85% of the running amount — when Mid-Level-Providers Mid-Level is present
  5. modifier 22 present → 120% 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
Self-Pay-Profee-With-Adjustments · no contract map1 base · 4 adj
no contract map — cannot be resolved
Base terms — first match wins
  1. 70% of the ChargeMaster-Profee fee schedule
Adjustments — all apply, in order
  1. multiple-procedure reduction (contract rules) — base codes 2; pays 100/71.42857% — when Modifier 26 is present
  2. multiple-procedure reduction (contract rules) — base codes 2; pays 100/71.42857% — when Modifier TC is present
  3. multiple-procedure reduction (contract rules) — base codes 2; pays 100/71.42857%
  4. multiple-procedure reduction (contract rules) — base codes 2; pays 100/71.42857%