Customer detail

SouthSoundRadiology

16
live contracts
2
cannot fire
18
calc types
12
SQL bodies
0
of those blocked
2
map conflicts

Methodology mix

ModifierAdjustment160
PercentOfFees25
MultipleProcedureAdjustment17
MultipleEndoscopyAdjustment16
FlatPercentOfCharges13
LesserOfAdjustment13
MedicareMultipleTherapyAdjustment13
ChargeLevelSqlAdjustment12
MedicareRVU8
SqlExpression6
PercentOfCharges3
MedicareLab3
MedicareDrug3
MedicareDME2
CalculationBuilder1
MultipleSurgeryAdjustment1
FlatFee1
BilateralSurgeryAdjustment1

Contracts

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

Aetna3 base · 14 adj
Aetna, Mailhandlers
Profee · all facilities · 2015-01-01 → 2099-12-31
Base terms — first match wins
  1. 100% of the Fixed-Fees fee schedule
  2. custom SQL — 90% of billed charges as the base allowed amount, restricted to CT procedure 76830 (transvaginal ultrasound).
  3. 85% of billed charges
Adjustments — all apply, in order
  1. multiple-procedure reduction (contract rules) — base codes 2; pays 100/50%
  2. Medicare multiple-therapy reduction (MPPR) — base codes 5; pays 100/50%
  3. multiple-endoscopy reduction (contract rules)
  4. modifier 22 present → 135% of the running amount
  5. modifier 50 present → 150% of the running amount
  6. modifier 52 present → 50% of the running amount
  7. modifier 54 present → 80% of the running amount
  8. modifier 62 present → 62.5% of the running amount
  9. modifier 78 present → 70% of the running amount
  10. modifier 80 present → 16% of the running amount
  11. modifier 81 present → 16% of the running amount
  12. modifier 82 present → 16% of the running amount
  13. modifier AS present → 13.6% of the running amount
  14. cap each charge and the account total at 100% of billed charges
ChargeLogic-Profee1 base · 0 adj
Charges
Profee · all facilities · 2015-01-01 → 2099-12-31
Base terms — first match wins
  1. 100% of the ChargeMaster-Profee fee schedule
Cigna2 base · 14 adj
Cigna
Profee · all facilities · 2015-01-01 → 2099-12-31
Base terms — first match wins
  1. 100% of the Fixed-Fees fee schedule
  2. 85% of billed charges
Adjustments — all apply, in order
  1. multiple-procedure reduction (contract rules) — base codes 2; pays 100/50%
  2. Medicare multiple-therapy reduction (MPPR) — base codes 5; pays 100/50%
  3. multiple-endoscopy reduction (contract rules)
  4. modifier 22 present → 135% of the running amount
  5. modifier 50 present → 150% of the running amount
  6. modifier 52 present → 50% of the running amount
  7. modifier 54 present → 80% of the running amount
  8. modifier 62 present → 62.5% of the running amount
  9. modifier 78 present → 70% of the running amount
  10. modifier 80 present → 16% of the running amount
  11. modifier 81 present → 16% of the running amount
  12. modifier 82 present → 16% of the running amount
  13. modifier AS present → 13.6% of the running amount
  14. cap each charge and the account total at 100% of billed charges
FirstChoice1 base · 14 adj
First Choice, Moda
Profee · all facilities · 2015-01-01 → 2099-12-31
Base terms — first match wins
  1. 85% of billed charges
Adjustments — all apply, in order
  1. multiple-procedure reduction (contract rules) — base codes 2; pays 100/50%
  2. Medicare multiple-therapy reduction (MPPR) — base codes 5; pays 100/50%
  3. multiple-endoscopy reduction (contract rules)
  4. modifier 22 present → 135% of the running amount
  5. modifier 50 present → 150% of the running amount
  6. modifier 52 present → 50% of the running amount
  7. modifier 54 present → 80% of the running amount
  8. modifier 62 present → 62.5% of the running amount
  9. modifier 78 present → 70% of the running amount
  10. modifier 80 present → 16% of the running amount
  11. modifier 81 present → 16% of the running amount
  12. modifier 82 present → 16% of the running amount
  13. modifier AS present → 13.6% of the running amount
  14. cap each charge and the account total at 100% of billed charges
Kaiser/GroupHealth2 base · 14 adj
Kaiser / Group Health
Profee · all facilities · 2015-01-01 → 2099-12-31
Base terms — first match wins
  1. custom SQL — A flat $104.52 fee for two specific radiology codes (77061, 77062), effective only for service dates on/after 2021-11-01.
  2. 100% of the Fixed-Fees fee schedule
Adjustments — all apply, in order
  1. multiple-procedure reduction (contract rules) — base codes 2; pays 100/50%
  2. Medicare multiple-therapy reduction (MPPR) — base codes 5; pays 100/50%
  3. multiple-endoscopy reduction (contract rules)
  4. modifier 22 present → 135% of the running amount
  5. modifier 50 present → 150% of the running amount
  6. modifier 52 present → 50% of the running amount
  7. modifier 54 present → 80% of the running amount
  8. modifier 62 present → 62.5% of the running amount
  9. modifier 78 present → 70% of the running amount
  10. modifier 80 present → 16% of the running amount
  11. modifier 81 present → 16% of the running amount
  12. modifier 82 present → 16% of the running amount
  13. modifier AS present → 13.6% of the running amount
  14. cap each charge and the account total at 100% of billed charges
Medicare-20165 base · 19 adj
AARP Medicare Complete, Medicare, Physicians of SW Washington, Premera Medicare, Regence Medicare, Soundpath Health
Profee · all facilities · 2016-01-01 → 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. 100% of billed charges
Adjustments — all apply, in order
  1. custom SQL — Pays a fixed flat dollar amount ($111.99) for breast ultrasound code 76981 for dates of service after 1/1/2021.
  2. custom SQL — Pays fixed flat dollar amounts for CT-scan codes 77061/77062 specific to one insurance ('Physicians of SW Washington'), and a separate flat amount for 77061 under Medicare, both restricted to dates of service on/after 11/1/2021.
  3. multiple-endoscopy reduction (contract rules)
  4. multiple-procedure reduction (contract rules) — base codes 2; pays 100/50%
  5. modifier 50 present → 150% of the running amount
  6. multiple-procedure reduction (contract rules) — base codes 2; pays 100/50%
  7. Medicare multiple-therapy reduction (MPPR) — base codes 5; pays 100/50%
  8. multiple-endoscopy reduction (contract rules)
  9. modifier 22 present → 135% of the running amount
  10. modifier 50 present → 150% of the running amount
  11. modifier 52 present → 50% of the running amount
  12. modifier 54 present → 80% of the running amount
  13. modifier 62 present → 62.5% of the running amount
  14. modifier 78 present → 70% of the running amount
  15. modifier 80 present → 16% of the running amount
  16. modifier 81 present → 16% of the running amount
  17. modifier 82 present → 16% of the running amount
  18. modifier AS present → 13.6% of the running amount
  19. cap each charge and the account total at 100% of billed charges
Premera2 base · 15 adj
Lifewise, Premera, Providence Health Plan
Profee · all facilities · 2015-01-01 → 2099-12-31
Base terms — first match wins
  1. custom SQL — Payer-specific flat pricing for CT bone-density codes 77061/77062 starting 11/1/2021: $90 for Lifewise, $150 for Premera.
  2. 100% of the Fixed-Fees fee schedule
Adjustments — all apply, in order
  1. custom SQL — ChargeLevelSqlAdjustment overriding charge type 20611 (arthrocentesis with ultrasound guidance) to a flat $142.79, unconditionally, with no date gate.
  2. multiple-procedure reduction (contract rules) — base codes 2; pays 100/50%
  3. Medicare multiple-therapy reduction (MPPR) — base codes 5; pays 100/50%
  4. multiple-endoscopy reduction (contract rules)
  5. modifier 22 present → 135% of the running amount
  6. modifier 50 present → 150% of the running amount
  7. modifier 52 present → 50% of the running amount
  8. modifier 54 present → 80% of the running amount
  9. modifier 62 present → 62.5% of the running amount
  10. modifier 78 present → 70% of the running amount
  11. modifier 80 present → 16% of the running amount
  12. modifier 81 present → 16% of the running amount
  13. modifier 82 present → 16% of the running amount
  14. modifier AS present → 13.6% of the running amount
  15. cap each charge and the account total at 100% of billed charges
Regence3 base · 14 adj
Healthcare Management, Regence, Regence Group Administrators
Profee · all facilities · 2015-01-01 → 2024-01-14
Base terms — first match wins
  1. custom SQL — A flat $150 override for CPT codes 77061/77062 (breast tomosynthesis-adjacent codes) for dates on/after 2021-11-01; returns no row for any other code or earlier date.
  2. 100% of the Fixed-Fees fee schedule
  3. flat $0
Adjustments — all apply, in order
  1. multiple-procedure reduction (contract rules) — base codes 2; pays 100/50%
  2. Medicare multiple-therapy reduction (MPPR) — base codes 5; pays 100/50%
  3. multiple-endoscopy reduction (contract rules)
  4. modifier 22 present → 135% of the running amount
  5. modifier 50 present → 150% of the running amount
  6. modifier 52 present → 50% of the running amount
  7. modifier 54 present → 80% of the running amount
  8. modifier 62 present → 62.5% of the running amount
  9. modifier 78 present → 70% of the running amount
  10. modifier 80 present → 16% of the running amount
  11. modifier 81 present → 16% of the running amount
  12. modifier 82 present → 16% of the running amount
  13. modifier AS present → 13.6% of the running amount
  14. cap each charge and the account total at 100% of billed charges
Regence-20246 base · 14 adj
Healthcare Management, Regence, Regence Group Administrators
Profee · all facilities · 2024-01-15 → 2999-12-31
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 fee schedule
  4. custom SQL — Hardcodes a flat $208 base amount for CT bone-density/DEXA-adjacent codes 77061/77062, a single blanket override with no date gate.
  5. 85% of Medicare drug
  6. 85% of Medicare lab
Adjustments — all apply, in order
  1. multiple-procedure reduction (contract rules) — base codes 2; pays 100/50%
  2. Medicare multiple-therapy reduction (MPPR) — base codes 5; pays 100/50%
  3. multiple-endoscopy reduction (contract rules)
  4. modifier 22 present → 135% of the running amount
  5. modifier 50 present → 150% of the running amount
  6. modifier 52 present → 50% of the running amount
  7. modifier 54 present → 80% of the running amount
  8. modifier 62 present → 62.5% of the running amount
  9. modifier 78 present → 70% of the running amount
  10. modifier 80 present → 16% of the running amount
  11. modifier 81 present → 16% of the running amount
  12. modifier 82 present → 16% of the running amount
  13. modifier AS present → 13.6% of the running amount
  14. cap each charge and the account total at 100% of billed charges
Regence-20245 base · 14 adj
Healthcare Management, Regence, Regence Group Administrators
Profee · all facilities · 2015-01-01 → 2099-12-31
Base terms — first match wins
  1. 100% of Medicare RVU (rates as of 2022-01-01)
  2. 100% of Medicare RVU (rates as of 2022-01-01)
  3. 100% of Medicare RVU (rates as of 2022-01-01)
  4. 100% of Medicare RVU (rates as of 2022-01-01)
  5. 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. Medicare multiple-therapy reduction (MPPR) — base codes 5; pays 100/50%
  3. multiple-endoscopy reduction (contract rules)
  4. modifier 22 present → 135% of the running amount
  5. modifier 50 present → 150% of the running amount
  6. modifier 52 present → 50% of the running amount
  7. modifier 54 present → 80% of the running amount
  8. modifier 62 present → 62.5% of the running amount
  9. modifier 78 present → 70% of the running amount
  10. modifier 80 present → 16% of the running amount
  11. modifier 81 present → 16% of the running amount
  12. modifier 82 present → 16% of the running amount
  13. modifier AS present → 13.6% of the running amount
  14. cap each charge and the account total at 100% of billed charges
Self-Pay2 base · 2 adj
Self Pay
Profee · all facilities · 2015-01-01 → 2099-12-31
Base terms — first match wins
  1. 100% of the Selfpay-Carveout fee schedule
  2. 70% of billed charges
Adjustments — all apply, in order
  1. custom SQL — ChargeLevelSqlAdjustment overriding charge type 76498 (unlisted radiology procedure) to a flat $405 for service dates after 2023-01-01.
  2. custom SQL — ChargeLevelSqlAdjustment overriding charge type 58340 (hysterosalpingography catheterization) to a flat $329.50 for service dates after 2024-01-01.
UnitedHealthcare3 base · 15 adj
United Healthcare
Profee · all facilities · 2015-01-01 → 2099-12-31
Base terms — first match wins
  1. custom SQL — Flat $116.91 fee for tomosynthesis mammography codes 77061/77062 on or after 11/1/2021, currently applied regardless of payer.
  2. 100% of the Fixed-Fees fee schedule
  3. 40% of billed charges
Adjustments — all apply, in order
  1. multiple-procedure reduction (contract rules) — base codes 2; pays 100/50%
  2. Medicare multiple-therapy reduction (MPPR) — base codes 5; pays 100/50%
  3. multiple-endoscopy reduction (contract rules)
  4. modifier 22 present → 135% of the running amount
  5. modifier 50 present → 150% of the running amount
  6. modifier 52 present → 50% of the running amount
  7. modifier 54 present → 80% of the running amount
  8. modifier 62 present → 62.5% of the running amount
  9. modifier 78 present → 70% of the running amount
  10. modifier 80 present → 16% of the running amount
  11. modifier 81 present → 16% of the running amount
  12. modifier 82 present → 16% of the running amount
  13. modifier AS present → 13.6% of the running amount
  14. modifier QZ present → 85% of the running amount
  15. cap each charge and the account total at 100% of billed charges
WA-Medicaid3 base · 15 adj
Community Health Plan WA, Medicaid
Profee · all facilities · 2015-01-01 → 2099-12-31
Base terms — first match wins
  1. 100% of the Medicaid-Drug fee schedule
  2. 100% of the Medicaid-RVU fee schedule
  3. 60% of billed charges
Adjustments — all apply, in order
  1. custom SQL — Applies a flat 5% markup to the allowed amount for any insurance whose name starts with 'Community Health Plan'.
  2. multiple-procedure reduction (contract rules) — base codes 2; pays 100/50%
  3. Medicare multiple-therapy reduction (MPPR) — base codes 5; pays 100/50%
  4. multiple-endoscopy reduction (contract rules)
  5. modifier 22 present → 135% of the running amount
  6. modifier 50 present → 150% of the running amount
  7. modifier 52 present → 50% of the running amount
  8. modifier 54 present → 80% of the running amount
  9. modifier 62 present → 62.5% of the running amount
  10. modifier 78 present → 70% of the running amount
  11. modifier 80 present → 16% of the running amount
  12. modifier 81 present → 16% of the running amount
  13. modifier 82 present → 16% of the running amount
  14. modifier AS present → 13.6% of the running amount
  15. cap each charge and the account total at 100% of billed charges
WA-Medicaid-Old9 base · 12 adj
Community Health Plan WA, Medicaid
Profee · all facilities · 2012-01-01 → 2014-12-31
Base terms — first match wins
  1. 60% of billed charges
  2. percent-of-charges, rate read from the WA-Medicaid-Drugs-POC schedule
  3. 100% of the WA-Medicaid-Drugs fee schedule
  4. 60% of the WA-Medicaid-DME-POC fee schedule
  5. 100% of the WA-Medicaid-DME fee schedule
  6. 100% of the WA-Medicaid-RVU fee schedule
  7. 60% of billed charges
  8. percent-of-charges, rate read from the WA-Medicaid-ASC-POC schedule
  9. 100% of the WA-Medicaid-ASC fee schedule
Adjustments — all apply, in order
  1. multiple-surgery reduction (contract rules) — pays 100/50%
  2. multiple-procedure reduction (contract rules) — base codes 2; pays 100/50%
  3. modifier 50 present → 150% of the running amount
  4. bilateral-surgery adjustment
  5. modifier 22 present → 135% of the running amount
  6. modifier 52 present → 90% of the running amount
  7. modifier 62 present → 62.5% of the running amount
  8. modifier 80 present → 16% of the running amount
  9. modifier 81 present → 16% of the running amount
  10. modifier 82 present → 16% of the running amount
  11. modifier AS present → 13.6% of the running amount
  12. modifier 78 present → 69% of the running amount
WA-Workers-Comp3 base · 15 adj
L & I / Workers Comp
Profee · all facilities · 2015-01-01 → 2099-12-31
Base terms — first match wins
  1. percent-of-charges, rate read from the WA-LI-Profee-POC schedule
  2. 100% of the WA-LI-Profee fee schedule
  3. 80% of billed charges
Adjustments — all apply, in order
  1. modifier 50 present → 50% of the running amount
  2. multiple-procedure reduction (contract rules) — base codes 2; pays 100/50%
  3. Medicare multiple-therapy reduction (MPPR) — base codes 5; pays 100/50%
  4. multiple-endoscopy reduction (contract rules)
  5. modifier 22 present → 135% of the running amount
  6. modifier 50 present → 150% of the running amount
  7. modifier 52 present → 50% of the running amount
  8. modifier 54 present → 80% of the running amount
  9. modifier 62 present → 62.5% of the running amount
  10. modifier 78 present → 70% of the running amount
  11. modifier 80 present → 16% of the running amount
  12. modifier 81 present → 16% of the running amount
  13. modifier 82 present → 16% of the running amount
  14. modifier AS present → 13.6% of the running amount
  15. cap each charge and the account total at 100% of billed charges
WellCare Medicare5 base · 16 adj
WellCare Medicare
Profee · all facilities · 2016-01-01 → 2999-12-31
Base terms — first match wins
  1. 105% of Medicare lab
  2. 105% of Medicare drug
  3. 105% of Medicare DME
  4. 105% of Medicare RVU
  5. 100% of billed charges
Adjustments — all apply, in order
  1. custom SQL — Pays a fixed flat dollar amount ($111.99) for breast ultrasound code 76981 for dates of service after 1/1/2021.
  2. custom SQL — Pays fixed flat dollar amounts for CT-scan codes 77061/77062 specific to one insurance ('Physicians of SW Washington'), and a separate flat amount for 77061 under Medicare, both restricted to dates of service on/after 11/1/2021.
  3. multiple-procedure reduction (contract rules) — base codes 2; pays 100/50%
  4. Medicare multiple-therapy reduction (MPPR) — base codes 5; pays 100/50%
  5. multiple-endoscopy reduction (contract rules)
  6. modifier 22 present → 135% of the running amount
  7. modifier 50 present → 150% of the running amount
  8. modifier 52 present → 50% of the running amount
  9. modifier 54 present → 80% of the running amount
  10. modifier 62 present → 62.5% of the running amount
  11. modifier 78 present → 70% of the running amount
  12. modifier 80 present → 16% of the running amount
  13. modifier 81 present → 16% of the running amount
  14. modifier 82 present → 16% of the running amount
  15. modifier AS present → 13.6% of the running amount
  16. cap each charge and the account total at 100% of billed charges

Cannot fire (2)

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

Medicare-2016-Backup · no contract map5 base · 13 adj
no contract map — cannot be resolved
Base terms — first match wins
  1. 100% of the Medicare-Drug 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. custom SQL — Pays a fixed flat dollar amount ($111.99) for breast ultrasound code 76981 for dates of service after 1/1/2021.
  2. custom SQL — Pays fixed flat dollar amounts for CT-scan codes 77061/77062 specific to one insurance ('Physicians of SW Washington'), and a separate flat amount for 77061 under Medicare, both restricted to dates of service on/after 11/1/2021.
  3. multiple-endoscopy reduction (contract rules)
  4. multiple-procedure reduction (contract rules) — base codes 2; pays 100/50%
  5. modifier 50 present → 150% of the running amount
  6. modifier 22 present → 135% of the running amount
  7. modifier 52 present → 90% of the running amount
  8. modifier 62 present → 62.5% 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 → 13.6% of the running amount
  13. modifier 78 present → 69% of the running amount
WellCare Medicare-Backup · no contract map5 base · 13 adj
no contract map — cannot be resolved
Base terms — first match wins
  1. 105% of the Medicare-Drug 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. custom SQL — Pays a fixed flat dollar amount ($111.99) for breast ultrasound code 76981 for dates of service after 1/1/2021.
  2. custom SQL — Pays fixed flat dollar amounts for CT-scan codes 77061/77062 specific to one insurance ('Physicians of SW Washington'), and a separate flat amount for 77061 under Medicare, both restricted to dates of service on/after 11/1/2021.
  3. multiple-endoscopy reduction (contract rules)
  4. multiple-procedure reduction (contract rules) — base codes 2; pays 100/50%
  5. modifier 50 present → 150% of the running amount
  6. modifier 22 present → 135% of the running amount
  7. modifier 52 present → 90% of the running amount
  8. modifier 62 present → 62.5% 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 → 13.6% of the running amount
  13. modifier 78 present → 69% of the running amount