Customer detail

SeaRad

26
live contracts
0
cannot fire
12
calc types
4
SQL bodies
0
of those blocked
1
map conflicts

Methodology mix

ModifierAdjustment102
PercentOfFees72
MultipleProcedureAdjustment14
LesserOfAdjustment14
FlatPercentOfCharges13
MultipleEndoscopyAdjustment8
ChargeLevelSqlAdjustment6
MedicareRVU6
PercentageAdjustment3
PercentOfCharges3
CalculationBuilder3
SqlExpression2

Contracts

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

AARP-Medicare-Complete5 base · 11 adj
AARP Medicare Complete
Professional · all facilities · 2019-01-01 → 2099-12-31
Base terms — first match wins
  1. 100% of the Medicare-Drug-ASP fee schedule
  2. 100% of the Medicare-Lab fee schedule
  3. 100% of the Medicare-DME fee schedule
  4. 100% of the Medicare-RVU fee schedule
  5. 100% of billed charges
Adjustments — all apply, in order
  1. multiple-endoscopy reduction (contract rules)
  2. multiple-procedure reduction (contract rules) — base codes 2; pays 100/50%
  3. modifier 50 present → 150% of the running amount
  4. modifier 22 present → 135% of the running amount
  5. modifier 52 present → 90% of the running amount
  6. modifier 62 present → 62.5% of the running amount
  7. modifier 80 present → 16% of the running amount
  8. modifier 81 present → 16% of the running amount
  9. modifier 82 present → 16% of the running amount
  10. modifier AS present → 13.6% of the running amount
  11. modifier 78 present → 69% of the running amount
Aetna5 base · 1 adj
Aetna, Carpenters Trust, Meritain
Professional · all facilities · 2019-01-01 → 2099-12-31
Base terms — first match wins
  1. 100% of the Carve-Outs fee schedule
  2. custom SQL — Computes the Medicare anesthesia allowed amount as (billed time units plus a physical-status modifier bonus for P3/P4/P5) times a hardcoded $43.00 conversion factor, restricted to procedure codes present in the CommonData anesthesia base-unit map.
  3. 100% of the RVU-Based fee schedule
  4. 100% of the Medicare-RVU fee schedule
  5. 100% of the Fixed-Fees fee schedule
Adjustments — all apply, in order
  1. cap each charge and the account total at 100% of billed charges
Aetna-Medicare5 base · 1 adj
Aetna Medicare
Professional · all facilities · 2019-01-01 → 2099-12-31
Base terms — first match wins
  1. 100% of the Carve-Outs fee schedule
  2. custom SQL — Computes the Medicare anesthesia allowed amount as (billed time units plus a physical-status modifier bonus for P3/P4/P5) times a hardcoded $43.00 conversion factor, restricted to procedure codes present in the CommonData anesthesia base-unit map.
  3. 100% of the RVU-Based fee schedule
  4. 100% of the Medicare-RVU fee schedule
  5. 100% of the Fixed-Fees fee schedule
Adjustments — all apply, in order
  1. cap each charge and the account total at 100% of billed charges
Amerigroup4 base · 11 adj
Amerigroup
Professional · all facilities · 2020-01-01 → 2099-12-31
Base terms — first match wins
  1. 105% of the Medicaid-Drug fee schedule
  2. 105% of the Medicaid-DME fee schedule
  3. 105% of the Medicaid-RVU fee schedule
  4. 60% of billed charges
Adjustments — all apply, in order
  1. multiple-procedure reduction (contract rules) — base codes 2; pays 100/50%
  2. modifier 22 present → 135% of the running amount
  3. modifier 50 present → 150% of the running amount
  4. modifier 52 present → 90% of the running amount
  5. modifier 62 present → 62.5% of the running amount
  6. modifier 80 present → 16% of the running amount
  7. modifier 81 present → 16% of the running amount
  8. modifier 82 present → 16% of the running amount
  9. modifier AS present → 13.6% of the running amount
  10. modifier 78 present → 69% of the running amount
  11. custom SQL — Applies a flat 5% markup to the allowed amount for any insurance whose name starts with 'Community Health Plan'.
ChargeLogic-Professional1 base · 1 adj
Charges
Professional · all facilities · 2019-01-01 → 2099-12-31
Base terms — first match wins
  1. 100% of the ChargeMaster-Professional fee schedule
Adjustments — all apply, in order
  1. custom SQL — Flat per-unit multiplier overrides for two specific supply codes: A9587 priced at Allowed*54 through end of 2024, and A9588 priced at Allowed*10 (no end date).
Cigna3 base · 1 adj
Cigna
Professional · all facilities · 2014-05-01 → 2099-12-31
Base terms — first match wins
  1. 100% of the Fixed-Fees fee schedule
  2. 100% of the RVU-Based fee schedule
  3. 50% of billed charges
Adjustments — all apply, in order
  1. cap each charge and the account total at 100% of billed charges
Community Health Plan Medicare5 base · 1 adj
Community Health Plan Medicare
Professional · all facilities · 2020-01-01 → 2099-12-31
Base terms — first match wins
  1. 100% of the DME-Based fee schedule
  2. 100% of the Drug-Based fee schedule
  3. 100% of the Lab-Based fee schedule
  4. 100% of the RVU-Based fee schedule
  5. percent-of-charges, rate read from the PET-Based schedule
Adjustments — all apply, in order
  1. cap each charge and the account total at 90% of billed charges
Community Health Plan WA4 base · 10 adj
Community Health Plan WA
Professional · all facilities · 2020-01-01 → 2099-12-31
Base terms — first match wins
  1. 103% of the Medicaid-Drug fee schedule
  2. 103% of the Medicaid-DME fee schedule
  3. 103% of the Medicaid-RVU fee schedule
  4. 60% of billed charges
Adjustments — all apply, in order
  1. multiple-procedure reduction (contract rules) — base codes 2; pays 100/50%
  2. modifier 22 present → 135% of the running amount
  3. modifier 50 present → 150% of the running amount
  4. modifier 52 present → 90% of the running amount
  5. modifier 62 present → 62.5% of the running amount
  6. modifier 80 present → 16% of the running amount
  7. modifier 81 present → 16% of the running amount
  8. modifier 82 present → 16% of the running amount
  9. modifier AS present → 13.6% of the running amount
  10. modifier 78 present → 69% of the running amount
First Choice5 base · 1 adj
First Choice
Professional · all facilities · 2020-01-01 → 2099-12-31
Base terms — first match wins
  1. 100% of the DME-Based fee schedule
  2. 100% of the Drug-Based fee schedule
  3. 100% of the Lab-Based fee schedule
  4. 100% of the RVU-Based fee schedule
  5. percent-of-charges, rate read from the PET-Based schedule
Adjustments — all apply, in order
  1. cap each charge and the account total at 90% of billed charges
Humana-Medicare5 base · 11 adj
Humana Medicare
Professional · all facilities · 2020-08-01 → 2099-12-31
Base terms — first match wins
  1. 105% of the Medicare-Drug-ASP fee schedule
  2. 105% of the Medicare-Lab fee schedule
  3. 105% of the Medicare-DME fee schedule
  4. 105% of the Medicare-RVU fee schedule
  5. 100% of billed charges
Adjustments — all apply, in order
  1. multiple-endoscopy reduction (contract rules)
  2. multiple-procedure reduction (contract rules) — base codes 2; pays 100/50%
  3. modifier 50 present → 150% of the running amount
  4. modifier 22 present → 135% of the running amount
  5. modifier 52 present → 90% of the running amount
  6. modifier 62 present → 62.5% of the running amount
  7. modifier 80 present → 16% of the running amount
  8. modifier 81 present → 16% of the running amount
  9. modifier 82 present → 16% of the running amount
  10. modifier AS present → 13.6% of the running amount
  11. modifier 78 present → 69% of the running amount
Kaiser / Group Health4 base · 12 adj
Kaiser / Group Health
Professional · all facilities · 2019-01-01 → 2099-12-31
Base terms — first match wins
  1. 100% of the Medicare-Drug-ASP fee schedule
  2. 100% of the Medicare-Lab fee schedule
  3. 100% of the Fixed-Fees fee schedule
  4. 70% of billed charges
Adjustments — all apply, in order
  1. multiple-endoscopy reduction (contract rules)
  2. multiple-procedure reduction (contract rules) — base codes 2; pays 100/50%
  3. modifier 50 present → 150% of the running amount
  4. modifier 22 present → 135% of the running amount
  5. modifier 52 present → 90% of the running amount
  6. modifier 62 present → 62.5% of the running amount
  7. modifier 80 present → 16% of the running amount
  8. modifier 81 present → 16% of the running amount
  9. modifier 82 present → 16% of the running amount
  10. modifier AS present → 13.6% of the running amount
  11. modifier 78 present → 69% of the running amount
  12. cap each charge and the account total at 100% of billed charges
Medicare6 base · 11 adj
Medicare
Professional · all facilities · 2014-01-01 → 2099-12-31
Base terms — first match wins
  1. 100% of the Carve-Outs fee schedule
  2. 100% of the Medicare-Drug-ASP fee schedule
  3. 100% of the Medicare-Lab fee schedule
  4. 100% of the Medicare-DME fee schedule
  5. 100% of the Medicare-RVU fee schedule
  6. 100% of billed charges
Adjustments — all apply, in order
  1. multiple-endoscopy reduction (contract rules)
  2. multiple-procedure reduction (contract rules) — base codes 2; pays 100/50%
  3. modifier 50 present → 150% of the running amount
  4. modifier 22 present → 135% of the running amount
  5. modifier 52 present → 90% of the running amount
  6. modifier 62 present → 62.5% of the running amount
  7. modifier 80 present → 16% of the running amount
  8. modifier 81 present → 16% of the running amount
  9. modifier 82 present → 16% of the running amount
  10. modifier AS present → 13.6% of the running amount
  11. modifier 78 present → 69% of the running amount
Molina5 base · 11 adj
Molina
Professional · all facilities · 2019-01-01 → 2099-12-31
Base terms — first match wins
  1. 165% of the Medicare-Drug-ASP fee schedule
  2. 165% of the Medicare-Lab fee schedule
  3. 165% of the Medicare-DME fee schedule
  4. 165% of the Medicare-RVU fee schedule
  5. 65% of billed charges
Adjustments — all apply, in order
  1. multiple-endoscopy reduction (contract rules)
  2. multiple-procedure reduction (contract rules) — base codes 2; pays 100/50%
  3. modifier 50 present → 150% of the running amount
  4. modifier 22 present → 135% of the running amount
  5. modifier 52 present → 90% of the running amount
  6. modifier 62 present → 62.5% of the running amount
  7. modifier 80 present → 16% of the running amount
  8. modifier 81 present → 16% of the running amount
  9. modifier 82 present → 16% of the running amount
  10. modifier AS present → 13.6% of the running amount
  11. modifier 78 present → 69% of the running amount
Molina-Medicare5 base · 11 adj
Molina Medicare
Professional · all facilities · 2019-01-01 → 2099-12-31
Base terms — first match wins
  1. 100% of the Medicare-Drug-ASP fee schedule
  2. 100% of the Medicare-Lab fee schedule
  3. 100% of the Medicare-DME fee schedule
  4. 100% of the Medicare-RVU fee schedule
  5. 60% of billed charges
Adjustments — all apply, in order
  1. multiple-endoscopy reduction (contract rules)
  2. multiple-procedure reduction (contract rules) — base codes 2; pays 100/50%
  3. modifier 50 present → 150% of the running amount
  4. modifier 22 present → 135% of the running amount
  5. modifier 52 present → 90% of the running amount
  6. modifier 62 present → 62.5% of the running amount
  7. modifier 80 present → 16% of the running amount
  8. modifier 81 present → 16% of the running amount
  9. modifier 82 present → 16% of the running amount
  10. modifier AS present → 13.6% of the running amount
  11. modifier 78 present → 69% of the running amount
MultiPlan1 base · 0 adj
MultiPlan
Professional · all facilities · 2010-05-01 → 2099-12-31
Base terms — first match wins
  1. 87% of billed charges
Premera2 base · 1 adj
Lifewise, Premera
Professional · all facilities · 2019-01-01 → 2099-12-31
Base terms — first match wins
  1. 100% of the RVU-Based fee schedule
  2. 100% of the Medicare-RVU fee schedule
Adjustments — all apply, in order
  1. cap each charge and the account total at 100% of billed charges
Premera-Medicare5 base · 12 adj
Premera Medicare
Professional · all facilities · 2019-01-01 → 2099-12-31
Base terms — first match wins
  1. 100% of the Medicare-Drug-ASP fee schedule
  2. 100% of the Medicare-Lab fee schedule
  3. 85% of the Medicare-DME fee schedule
  4. 100% of the Medicare-RVU fee schedule
  5. 60% of billed charges
Adjustments — all apply, in order
  1. multiple-endoscopy reduction (contract rules)
  2. multiple-procedure reduction (contract rules) — base codes 2; pays 100/50%
  3. modifier 50 present → 150% of the running amount
  4. modifier 22 present → 135% of the running amount
  5. modifier 52 present → 90% of the running amount
  6. modifier 62 present → 62.5% of the running amount
  7. modifier 80 present → 16% of the running amount
  8. modifier 81 present → 16% of the running amount
  9. modifier 82 present → 16% of the running amount
  10. modifier AS present → 13.6% of the running amount
  11. modifier 78 present → 69% of the running amount
  12. cap each charge and the account total at 100% of billed charges
Regence4 base · 1 adj
Healthcare Management Administrators, Regence, Regence Group Administrators
Professional · all facilities · 2019-01-01 → 2024-01-14
Base terms — first match wins
  1. 100% of the Medicare-Lab fee schedule
  2. 100% of the RVU-Based fee schedule
  3. 100% of the Medicare-RVU fee schedule
  4. 100% of the Fixed-Fees fee schedule
Adjustments — all apply, in order
  1. cap each charge and the account total at 100% of billed charges
Regence-20244 base · 5 adj
Healthcare Management Administrators, Regence, Regence Group Administrators
Professional · all facilities · 2024-01-15 → 2025-01-14
Base terms — first match wins
  1. computed expression (operands follow)
  2. 100% of Medicare RVU (rates as of 2022-01-01)
  3. Multiply 100% of the Fixed-Fees-Multiplier fee schedule
  4. 100% of Medicare RVU (rates as of 2022-01-01)
Adjustments — all apply, in order
  1. multiple-procedure reduction (contract rules) — base codes 2; pays 100/50%
  2. modifier 50 present → 150% of the running amount
  3. rescale by a percentage read from the Mid-Level-Charges schedule — when MidLevelProviders Mid-Level is present
  4. cap each charge and the account total at 100% of billed charges
  5. custom SQL — Hardcoded flat fee of $163.59 for CPT 90837 (60-minute psychotherapy), independent of any other charge attributes.
Regence-20254 base · 5 adj
Healthcare Management Administrators, Regence, Regence Group Administrators
Professional · all facilities · 2025-01-15 → 2026-01-14
Base terms — first match wins
  1. computed expression (operands follow)
  2. 100% of Medicare RVU (rates as of 2022-01-01)
  3. Multiply 100% of the Fixed-Fees-Multiplier fee schedule
  4. 100% of Medicare RVU (rates as of 2022-01-01)
Adjustments — all apply, in order
  1. multiple-procedure reduction (contract rules) — base codes 2; pays 100/50%
  2. modifier 50 present → 150% of the running amount
  3. rescale by a percentage read from the Mid-Level-Charges schedule — when MidLevelProviders Mid-Level is present
  4. cap each charge and the account total at 100% of billed charges
  5. custom SQL — Hardcoded flat fee of $163.59 for CPT 90837 (60-minute psychotherapy), independent of any other charge attributes.
Regence-20264 base · 5 adj
Healthcare Management Administrators, Regence, Regence Group Administrators
Professional · all facilities · 2026-01-15 → 2099-12-31
Base terms — first match wins
  1. computed expression (operands follow)
  2. 100% of Medicare RVU (rates as of 2022-01-01)
  3. Multiply 100% of the Fixed-Fees-Multiplier fee schedule
  4. 100% of Medicare RVU (rates as of 2022-01-01)
Adjustments — all apply, in order
  1. multiple-procedure reduction (contract rules) — base codes 2; pays 100/50%
  2. modifier 50 present → 150% of the running amount
  3. rescale by a percentage read from the Mid-Level-Charges schedule — when MidLevelProviders Mid-Level is present
  4. cap each charge and the account total at 100% of billed charges
  5. custom SQL — Hardcoded flat fee of $163.59 for CPT 90837 (60-minute psychotherapy), independent of any other charge attributes.
Regence-Medicare4 base · 12 adj
Regence Medicare
Professional · all facilities · 2019-01-01 → 2099-12-31
Base terms — first match wins
  1. 100% of the Medicare-Drug-ASP fee schedule
  2. 90% of the Medicare-Lab fee schedule
  3. 100% of the Medicare-DME fee schedule
  4. 102% of the Medicare-RVU fee schedule
Adjustments — all apply, in order
  1. multiple-endoscopy reduction (contract rules)
  2. multiple-procedure reduction (contract rules) — base codes 2; pays 100/50%
  3. modifier 50 present → 150% of the running amount
  4. modifier 22 present → 135% of the running amount
  5. modifier 52 present → 90% of the running amount
  6. modifier 62 present → 62.5% of the running amount
  7. modifier 80 present → 16% of the running amount
  8. modifier 81 present → 16% of the running amount
  9. modifier 82 present → 16% of the running amount
  10. modifier AS present → 13.6% of the running amount
  11. modifier 78 present → 69% of the running amount
  12. cap each charge and the account total at 100% of billed charges
Self-Pay2 base · 0 adj
Self Pay
Professional · all facilities · 2020-01-01 → 2999-12-31
Base terms — first match wins
  1. 100% of the Carve-Outs fee schedule
  2. percent-of-charges, rate read from the Fixed-Fees schedule
Self-Pay-20242 base · 0 adj
Self Pay
Professional · all facilities · 2024-08-19 → 2999-12-31
Base terms — first match wins
  1. 100% of the Carve-Outs fee schedule
  2. 75% of billed charges
UnitedHealthcare1 base · 1 adj
UMR, United Healthcare
Professional · all facilities · 2022-02-01 → 2099-12-31
UMR, United Healthcare
Professional · all facilities · 2015-12-01 → 2021-03-15
Base terms — first match wins
  1. 100% of the RVU-Based fee schedule
Adjustments — all apply, in order
  1. cap each charge and the account total at 100% of billed charges
WA-Medicaid4 base · 11 adj
Medicaid
Professional · all facilities · 2018-01-01 → 2099-12-31
Base terms — first match wins
  1. 100% of the Medicaid-Drug fee schedule
  2. 100% of the Medicaid-DME fee schedule
  3. 100% of the Medicaid-RVU fee schedule
  4. 60% of billed charges
Adjustments — all apply, in order
  1. multiple-procedure reduction (contract rules) — base codes 2; pays 100/50%
  2. modifier 22 present → 135% of the running amount
  3. modifier 50 present → 150% of the running amount
  4. modifier 52 present → 90% of the running amount
  5. modifier 62 present → 62.5% of the running amount
  6. modifier 80 present → 16% of the running amount
  7. modifier 81 present → 16% of the running amount
  8. modifier 82 present → 16% of the running amount
  9. modifier AS present → 13.6% of the running amount
  10. modifier 78 present → 69% of the running amount
  11. custom SQL — Applies a flat 5% markup to the allowed amount for any insurance whose name starts with 'Community Health Plan'.