Customer detail

TFOC

0
live contracts
30
cannot fire
10
calc types
6
SQL bodies
0
of those blocked
0
map conflicts

Methodology mix

ModifierAdjustment325
PercentOfFees125
LesserOfAdjustment29
MultipleProcedureAdjustment29
MultipleEndoscopyAdjustment28
FlatPercentOfCharges24
PercentageAdjustment18
ChargeLevelSqlAdjustment10
MultiplePhysiotherapyAdjustment4
SqlExpression3

Contracts

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

Cannot fire (30)

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

Aetna-Commercial · no contract map10 base · 15 adj
no contract map — cannot be resolved
Base terms — first match wins
  1. 185% of the Profee-Clinic-Surgery fee schedule — when PlaceOfServiceCategory Clinic is present
  2. 185% of the Profee-Hospital-Surgery fee schedule — when PlaceOfServiceCategory Clinic is absent
  3. 100% of the Profee-Clinic-HCPC fee schedule — when PlaceOfServiceCategory Clinic is present
  4. 100% of the Profee-Hospital-HCPC fee schedule — when PlaceOfServiceCategory Clinic is absent
  5. 155% of the Medicare-DME fee schedule
  6. 155% of the Medicare-Lab fee schedule
  7. 155% of the Medicare-Drug fee schedule
  8. 155% of the Profee-Clinic fee schedule — when PlaceOfServiceCategory Clinic is present
  9. 155% of the Profee-Hospital fee schedule — when PlaceOfServiceCategory Clinic is absent
  10. 65% of billed charges
Adjustments — all apply, in order
  1. modifier 1 present → 0% of the running amount
  2. multiple-endoscopy reduction (contract rules)
  3. multiple-procedure reduction (contract rules) — base codes 2; pays 100/50%
  4. rescale by a percentage read from the Mid-Level-Charges schedule — when IsMidLevelProvider Yes is present
  5. modifier 22 present → 135% of the running amount
  6. modifier 50 present → 150% of the running amount
  7. modifier 52 present → 50% of the running amount
  8. modifier 54 present → 80% of the running amount
  9. modifier 62 present → 62.5% of the running amount
  10. modifier 78 present → 70% of the running amount
  11. modifier 80 present → 16% of the running amount
  12. modifier 81 present → 16% of the running amount
  13. modifier 82 present → 16% of the running amount
  14. modifier AS present → 13.6% of the running amount
  15. cap each charge and the account total at 100% of billed charges
Aetna-Commercial-2021 · no contract map2 base · 16 adj
no contract map — cannot be resolved
Base terms — first match wins
  1. custom SQL — Medicare anesthesia allowed amount: base units for the anesthesia procedure code plus time units (billed units/15-minute increments), times a flat $37 conversion factor — a simplified, non-locality-adjusted version of the standard Medicare anesthesia formula.
  2. 100% of the Fixed-Fees-Secondary fee schedule
Adjustments — all apply, in order
  1. modifier 1 present → 0% of the running amount
  2. multiple-endoscopy reduction (contract rules)
  3. multiple-procedure reduction (contract rules) — base codes 2; pays 100/50%
  4. rescale by a percentage read from the Mid-Level-Charges schedule — when IsMidLevelProvider Yes is present
  5. modifier 22 present → 135% of the running amount
  6. modifier 50 present → 150% of the running amount
  7. modifier 52 present → 50% of the running amount
  8. modifier 54 present → 80% of the running amount
  9. modifier 62 present → 62.5% of the running amount
  10. modifier 78 present → 70% of the running amount
  11. modifier 80 present → 16% of the running amount
  12. modifier 81 present → 16% of the running amount
  13. modifier 82 present → 16% of the running amount
  14. modifier AS present → 13.6% of the running amount
  15. modifier QX present → 50% of the running amount
  16. cap each charge and the account total at 100% of billed charges
Aetna-MA · no contract map5 base · 15 adj
no contract map — cannot be resolved
Base terms — first match wins
  1. 100% of the Medicare-DME fee schedule
  2. 60% of the Medicare-Lab fee schedule
  3. 100% of the Medicare-Drug fee schedule
  4. 100% of the Profee-Clinic fee schedule — when PlaceOfServiceCategory Clinic is present
  5. 100% of the Profee-Hospital fee schedule — when PlaceOfServiceCategory Clinic is absent
Adjustments — all apply, in order
  1. modifier 1 present → 0% of the running amount
  2. multiple-endoscopy reduction (contract rules)
  3. multiple-procedure reduction (contract rules) — base codes 2; pays 100/50%
  4. rescale by a percentage read from the Mid-Level-Charges schedule — when IsMidLevelProvider Yes is present
  5. modifier 22 present → 135% of the running amount
  6. modifier 50 present → 150% of the running amount
  7. modifier 52 present → 50% of the running amount
  8. modifier 54 present → 80% of the running amount
  9. modifier 62 present → 62.5% of the running amount
  10. modifier 78 present → 70% of the running amount
  11. modifier 80 present → 16% of the running amount
  12. modifier 81 present → 16% of the running amount
  13. modifier 82 present → 16% of the running amount
  14. modifier AS present → 13.6% of the running amount
  15. cap each charge and the account total at 100% of billed charges
BCBS-NV · no contract map5 base · 18 adj
no contract map — cannot be resolved
Base terms — first match wins
  1. custom SQL — A flat $37.12 override for lab code 80307 (drug screen confirmation) for dates on/after 2019-07-01, per referenced support ticket #8293; no fallback for other codes/dates.
  2. 70% of the Medicare-DME fee schedule
  3. 106% of the Medicare-Drug fee schedule
  4. 100% of the Profee-Hospital fee schedule — when PlaceOfServiceCategory Clinic is absent
  5. 100% of the Profee-Clinic fee schedule — when PlaceOfServiceCategory Clinic is present
Adjustments — all apply, in order
  1. modifier 1 present → 0% of the running amount
  2. multiple-endoscopy reduction (contract rules)
  3. multiple-procedure reduction (contract rules) — base codes 2, 3; pays 100/25%
  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 QK present → 50% of the running amount
  15. modifier QY present → 50% of the running amount
  16. modifier QX present → 50% of the running amount
  17. cap each charge and the account total at 100% of billed charges
  18. custom SQL — Zeroes out payment for outpatient consultation E&M codes 99241-99246 for dates of service on/after 10/1/2018 -- CMS retired these consult codes from Medicare payment in 2010, and this rule enforces that for this contract/date.
BCBS-NV-2020 · no contract map7 base · 18 adj
no contract map — cannot be resolved
Base terms — first match wins
  1. 100% of the Fixed-Fees fee schedule
  2. 70% of the Medicare-DME fee schedule
  3. 100% of the Medicare-Lab fee schedule
  4. 106% of the Medicare-Drug fee schedule
  5. 100% of the Profee-Hospital fee schedule — when PlaceOfServiceCategory Clinic is absent
  6. 100% of the Profee-Clinic fee schedule — when PlaceOfServiceCategory Clinic is present
  7. 80% of billed charges — when IsMidLevelProvider Yes is present
Adjustments — all apply, in order
  1. modifier 1 present → 0% of the running amount
  2. multiple-endoscopy reduction (contract rules)
  3. multiple-procedure reduction (contract rules) — base codes 2, 3; pays 100/25%
  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 → 16% of the running amount
  14. modifier QK present → 50% of the running amount
  15. modifier QY present → 50% of the running amount
  16. modifier QX present → 50% of the running amount
  17. cap each charge and the account total at 100% of billed charges
  18. custom SQL — Zeroes out payment for outpatient consultation E&M codes 99241-99246 for dates of service on/after 10/1/2018 -- CMS retired these consult codes from Medicare payment in 2010, and this rule enforces that for this contract/date.
BCBS-NV-2020-With-MidLevel · no contract map9 base · 18 adj
no contract map — cannot be resolved
Base terms — first match wins
  1. 100% of the Fixed-Fees fee schedule
  2. 70% of the Medicare-DME fee schedule
  3. 100% of the Medicare-Lab fee schedule
  4. 106% of the Medicare-Drug fee schedule
  5. 100% of the Profee-Hospital-MidLevel fee schedule — when PlaceOfServiceCategory Clinic is absent; IsMidLevelProvider Yes is present
  6. 100% of the Profee-Clinic-MidLevel fee schedule — when PlaceOfServiceCategory Clinic is present; IsMidLevelProvider Yes is present
  7. 100% of the Profee-Hospital fee schedule — when PlaceOfServiceCategory Clinic is absent; IsMidLevelProvider Yes is absent
  8. 100% of the Profee-Clinic fee schedule — when PlaceOfServiceCategory Clinic is present; IsMidLevelProvider Yes is absent
  9. 80% of billed charges — when IsMidLevelProvider Yes is present
Adjustments — all apply, in order
  1. modifier 1 present → 0% of the running amount
  2. multiple-endoscopy reduction (contract rules)
  3. multiple-procedure reduction (contract rules) — base codes 2, 3; pays 100/25%
  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 → 16% of the running amount
  14. modifier QK present → 50% of the running amount
  15. modifier QY present → 50% of the running amount
  16. modifier QX present → 50% of the running amount
  17. cap each charge and the account total at 100% of billed charges
  18. custom SQL — Zeroes out payment for outpatient consultation E&M codes 99241-99246 for dates of service on/after 10/1/2018 -- CMS retired these consult codes from Medicare payment in 2010, and this rule enforces that for this contract/date.
BCBS-NV-2022 · no contract map5 base · 18 adj
no contract map — cannot be resolved
Base terms — first match wins
  1. 100% of the Fixed-Fees fee schedule
  2. 70% of the Medicare-DME fee schedule
  3. 106% of the Medicare-Drug fee schedule
  4. 100% of the Fixed-Fees-Hospital fee schedule — when PlaceOfServiceCategory Clinic is absent
  5. 100% of the Fixed-Fees-Clinic fee schedule — when PlaceOfServiceCategory Clinic is present
Adjustments — all apply, in order
  1. modifier 1 present → 0% of the running amount
  2. multiple-endoscopy reduction (contract rules)
  3. multiple-procedure reduction (contract rules) — base codes 2, 3; pays 100/25%
  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 → 16% of the running amount
  14. modifier QK present → 50% of the running amount
  15. modifier QY present → 50% of the running amount
  16. modifier QX present → 50% of the running amount
  17. cap each charge and the account total at 100% of billed charges
  18. custom SQL — Zeroes out payment for outpatient consultation E&M codes 99241-99246 for dates of service on/after 10/1/2018 -- CMS retired these consult codes from Medicare payment in 2010, and this rule enforces that for this contract/date.
BCBS-NV-Medicare-Advantage · no contract map7 base · 18 adj
no contract map — cannot be resolved
Base terms — first match wins
  1. 95% of the Medicare-DME fee schedule
  2. 95% of the Medicare-Lab fee schedule
  3. 95% of the Medicare-Drug fee schedule
  4. 95% of the Fixed-Fees fee schedule
  5. 95% of the Profee-Clinic fee schedule — when PlaceOfServiceCategory Clinic is present
  6. 95% of the Profee-Hospital fee schedule — when PlaceOfServiceCategory Clinic is absent
  7. 100% of billed charges
Adjustments — all apply, in order
  1. custom SQL — Applies the shared CommonData Medicare sequestration reduction to a charge's allowed amount by calling a scalar SQL function, evidently for a plan whose FeeLogic isn't flagged Medicare-based (the engine's automatic MedicareSequestrationAdjustment only fires for Medicare-based FeeLogics).
  2. modifier 1 present → 0% of the running amount
  3. multiple-endoscopy reduction (contract rules)
  4. multiple-procedure reduction (contract rules) — base codes 2; pays 100/50%
  5. multiple-physiotherapy reduction — when PlaceOfServiceCategory Clinic is present
  6. multiple-physiotherapy reduction — when PlaceOfServiceCategory Clinic is absent
  7. rescale by a percentage read from the Mid-Level-Charges schedule — when IsMidLevelProvider Yes is present
  8. modifier 22 present → 135% of the running amount
  9. modifier 50 present → 150% of the running amount
  10. modifier 52 present → 50% of the running amount
  11. modifier 54 present → 80% of the running amount
  12. modifier 62 present → 62.5% of the running amount
  13. modifier 78 present → 70% of the running amount
  14. modifier 80 present → 16% of the running amount
  15. modifier 81 present → 16% of the running amount
  16. modifier 82 present → 16% of the running amount
  17. modifier AS present → 16% of the running amount
  18. cap each charge and the account total at 100% of billed charges
ChargeMaster · no contract map1 base · 0 adj
no contract map — cannot be resolved
Base terms — first match wins
  1. 100% of the ChargeMaster fee schedule
ChoiceCare-2001-07 · no contract map1 base · 15 adj
no contract map — cannot be resolved
Base terms — first match wins
  1. 85% of billed charges
Adjustments — all apply, in order
  1. modifier 1 present → 0% of the running amount
  2. multiple-endoscopy reduction (contract rules)
  3. multiple-procedure reduction (contract rules) — base codes 2; pays 100/50%
  4. rescale by a percentage read from the Mid-Level-Charges schedule — when IsMidLevelProvider Yes is present
  5. modifier 22 present → 135% of the running amount
  6. modifier 50 present → 150% of the running amount
  7. modifier 52 present → 50% of the running amount
  8. modifier 54 present → 80% of the running amount
  9. modifier 62 present → 62.5% of the running amount
  10. modifier 78 present → 70% of the running amount
  11. modifier 80 present → 16% of the running amount
  12. modifier 81 present → 16% of the running amount
  13. modifier 82 present → 16% of the running amount
  14. modifier AS present → 13.6% of the running amount
  15. cap each charge and the account total at 100% of billed charges
Cigna · no contract map3 base · 15 adj
no contract map — cannot be resolved
Base terms — first match wins
  1. 100% of the Profee-Hospital fee schedule — when PlaceOfServiceCategory Clinic is absent
  2. 100% of the Profee-Clinic fee schedule — when PlaceOfServiceCategory Clinic is present
  3. 80% of billed charges
Adjustments — all apply, in order
  1. modifier 1 present → 0% of the running amount
  2. multiple-endoscopy reduction (contract rules)
  3. multiple-procedure reduction (contract rules) — base codes 2; pays 100/50%
  4. rescale by a percentage read from the Mid-Level-Charges schedule — when IsMidLevelProvider Yes is present
  5. modifier 22 present → 135% of the running amount
  6. modifier 50 present → 150% of the running amount
  7. modifier 52 present → 50% of the running amount
  8. modifier 54 present → 80% of the running amount
  9. modifier 62 present → 62.5% of the running amount
  10. modifier 78 present → 70% of the running amount
  11. modifier 80 present → 16% of the running amount
  12. modifier 81 present → 16% of the running amount
  13. modifier 82 present → 16% of the running amount
  14. modifier AS present → 13.6% of the running amount
  15. cap each charge and the account total at 100% of billed charges
FirstHealth · no contract map4 base · 15 adj
no contract map — cannot be resolved
Base terms — first match wins
  1. 100% of the Medicare-DME fee schedule
  2. 100% of the Profee-Clinic fee schedule — when PlaceOfServiceCategory Clinic is present
  3. 100% of the Profee-Hospital fee schedule — when PlaceOfServiceCategory Clinic is absent
  4. 60% of billed charges
Adjustments — all apply, in order
  1. modifier 1 present → 0% of the running amount
  2. multiple-endoscopy reduction (contract rules)
  3. multiple-procedure reduction (contract rules) — base codes 2; pays 100/50%
  4. rescale by a percentage read from the Mid-Level-Charges schedule — when IsMidLevelProvider Yes is present
  5. modifier 22 present → 135% of the running amount
  6. modifier 50 present → 150% of the running amount
  7. modifier 52 present → 50% of the running amount
  8. modifier 54 present → 80% of the running amount
  9. modifier 62 present → 62.5% of the running amount
  10. modifier 78 present → 70% of the running amount
  11. modifier 80 present → 16% of the running amount
  12. modifier 81 present → 16% of the running amount
  13. modifier 82 present → 16% of the running amount
  14. modifier AS present → 13.6% of the running amount
  15. cap each charge and the account total at 100% of billed charges
HHP · no contract map6 base · 14 adj
no contract map — cannot be resolved
Base terms — first match wins
  1. 100% of the Fixed-Fees fee schedule
  2. 100% of the Medicare-DME fee schedule
  3. 100% of the Fixed-Fees-Lab fee schedule
  4. 100% of the Profee-Hospital fee schedule — when PlaceOfServiceCategory Clinic is absent
  5. 100% of the Profee-Clinic fee schedule — when PlaceOfServiceCategory Clinic is present
  6. 70% of billed charges
Adjustments — all apply, in order
  1. modifier 1 present → 0% of the running amount
  2. multiple-endoscopy reduction (contract rules)
  3. multiple-procedure reduction (contract rules) — base codes 2; pays 100/50%
  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
HHP Medicare Advantage · no contract map6 base · 14 adj
no contract map — cannot be resolved
Base terms — first match wins
  1. 65% of the Medicare-DME fee schedule
  2. 100% of the Medicare-Lab fee schedule
  3. 100% of the Medicare-Drug fee schedule
  4. 100% of the Profee-Clinic fee schedule — when PlaceOfServiceCategory Clinic is present
  5. 100% of the Profee-Hospital fee schedule — when PlaceOfServiceCategory Clinic is absent
  6. 50% of billed charges
Adjustments — all apply, in order
  1. modifier 1 present → 0% of the running amount
  2. multiple-endoscopy reduction (contract rules)
  3. multiple-procedure reduction (contract rules) — base codes 2; pays 100/50%
  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
HHP Medicare Advantage-With-MidLevel · no contract map6 base · 15 adj
no contract map — cannot be resolved
Base terms — first match wins
  1. 65% of the Medicare-DME fee schedule
  2. 100% of the Medicare-Lab fee schedule
  3. 100% of the Medicare-Drug fee schedule
  4. 100% of the Profee-Clinic fee schedule — when PlaceOfServiceCategory Clinic is present
  5. 100% of the Profee-Hospital fee schedule — when PlaceOfServiceCategory Clinic is absent
  6. 50% of billed charges
Adjustments — all apply, in order
  1. modifier 1 present → 0% of the running amount
  2. multiple-endoscopy reduction (contract rules)
  3. multiple-procedure reduction (contract rules) — base codes 2; pays 100/50%
  4. rescale by a percentage read from the Mid-Level-Charges schedule — when IsMidLevelProvider Yes is present
  5. modifier 22 present → 135% of the running amount
  6. modifier 50 present → 150% of the running amount
  7. modifier 52 present → 50% of the running amount
  8. modifier 54 present → 80% of the running amount
  9. modifier 62 present → 62.5% of the running amount
  10. modifier 78 present → 70% of the running amount
  11. modifier 80 present → 16% of the running amount
  12. modifier 81 present → 16% of the running amount
  13. modifier 82 present → 16% of the running amount
  14. modifier AS present → 13.6% of the running amount
  15. cap each charge and the account total at 100% of billed charges
HHP-2019-01 · no contract map6 base · 15 adj
no contract map — cannot be resolved
Base terms — first match wins
  1. 100% of the Fixed-Fees fee schedule
  2. 100% of the Medicare-DME fee schedule
  3. 100% of the Fixed-Fees-Lab fee schedule
  4. 100% of the Profee-Hospital fee schedule — when PlaceOfServiceCategory Clinic is absent
  5. 100% of the Profee-Clinic fee schedule — when PlaceOfServiceCategory Clinic is present
  6. 70% of billed charges
Adjustments — all apply, in order
  1. modifier 1 present → 0% of the running amount
  2. multiple-endoscopy reduction (contract rules)
  3. multiple-procedure reduction (contract rules) — base codes 2; pays 100/50%
  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. custom SQL — Pays fixed flat dollar amounts for two radiology codes (72141 MRI spine, 72148 MRI lumbar) specifically when billed with the technical-component ('TC') modifier.
  15. cap each charge and the account total at 100% of billed charges
HHP-2019-01-With-MidLevel · no contract map6 base · 16 adj
no contract map — cannot be resolved
Base terms — first match wins
  1. 100% of the Fixed-Fees fee schedule
  2. 100% of the Medicare-DME fee schedule
  3. 100% of the Fixed-Fees-Lab fee schedule
  4. 100% of the Profee-Hospital fee schedule — when PlaceOfServiceCategory Clinic is absent
  5. 100% of the Profee-Clinic fee schedule — when PlaceOfServiceCategory Clinic is present
  6. 70% of billed charges
Adjustments — all apply, in order
  1. modifier 1 present → 0% of the running amount
  2. multiple-endoscopy reduction (contract rules)
  3. multiple-procedure reduction (contract rules) — base codes 2; pays 100/50%
  4. rescale by a percentage read from the Mid-Level-Charges schedule — when IsMidLevelProvider Yes is present
  5. modifier 22 present → 135% of the running amount
  6. modifier 50 present → 150% of the running amount
  7. modifier 52 present → 50% of the running amount
  8. modifier 54 present → 80% of the running amount
  9. modifier 62 present → 62.5% of the running amount
  10. modifier 78 present → 70% of the running amount
  11. modifier 80 present → 16% of the running amount
  12. modifier 81 present → 16% of the running amount
  13. modifier 82 present → 16% of the running amount
  14. modifier AS present → 13.6% of the running amount
  15. custom SQL — Pays fixed flat dollar amounts for two radiology codes (72141 MRI spine, 72148 MRI lumbar) specifically when billed with the technical-component ('TC') modifier.
  16. cap each charge and the account total at 100% of billed charges
HHP-2022-01 · no contract map4 base · 15 adj
no contract map — cannot be resolved
Base terms — first match wins
  1. 70% of the Medicare-DME fee schedule
  2. 135% of the Profee-Hospital fee schedule — when PlaceOfServiceCategory Clinic is absent
  3. 135% of the Profee-Clinic fee schedule — when PlaceOfServiceCategory Clinic is present
  4. 100% of the Fixed-Fees-Secondary fee schedule
Adjustments — all apply, in order
  1. modifier 1 present → 0% of the running amount
  2. multiple-endoscopy reduction (contract rules)
  3. multiple-procedure reduction (contract rules) — base codes 2; pays 100/50%
  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. custom SQL — Pays fixed flat dollar amounts for two radiology codes (72141 MRI spine, 72148 MRI lumbar) specifically when billed with the technical-component ('TC') modifier.
  15. cap each charge and the account total at 100% of billed charges
HHP-With-MidLevel · no contract map5 base · 15 adj
no contract map — cannot be resolved
Base terms — first match wins
  1. 100% of the Medicare-DME fee schedule
  2. 100% of the Fixed-Fees-Lab fee schedule
  3. 100% of the Profee-Hospital fee schedule — when PlaceOfServiceCategory Clinic is absent
  4. 100% of the Profee-Clinic fee schedule — when PlaceOfServiceCategory Clinic is present
  5. 70% of billed charges
Adjustments — all apply, in order
  1. modifier 1 present → 0% of the running amount
  2. multiple-endoscopy reduction (contract rules)
  3. multiple-procedure reduction (contract rules) — base codes 2; pays 100/50%
  4. rescale by a percentage read from the Mid-Level-Charges schedule — when IsMidLevelProvider Yes is present
  5. modifier 22 present → 135% of the running amount
  6. modifier 50 present → 150% of the running amount
  7. modifier 52 present → 50% of the running amount
  8. modifier 54 present → 80% of the running amount
  9. modifier 62 present → 62.5% of the running amount
  10. modifier 78 present → 70% of the running amount
  11. modifier 80 present → 16% of the running amount
  12. modifier 81 present → 16% of the running amount
  13. modifier 82 present → 16% of the running amount
  14. modifier AS present → 13.6% of the running amount
  15. cap each charge and the account total at 100% of billed charges
HealthNet · no contract map1 base · 15 adj
no contract map — cannot be resolved
Base terms — first match wins
  1. 90% of billed charges — when HealthNetProviders Contracted is present
Adjustments — all apply, in order
  1. modifier 1 present → 0% of the running amount
  2. multiple-endoscopy reduction (contract rules)
  3. multiple-procedure reduction (contract rules) — base codes 2; pays 100/50%
  4. rescale by a percentage read from the Mid-Level-Charges schedule — when IsMidLevelProvider Yes is present
  5. modifier 22 present → 135% of the running amount
  6. modifier 50 present → 150% of the running amount
  7. modifier 52 present → 50% of the running amount
  8. modifier 54 present → 80% of the running amount
  9. modifier 62 present → 62.5% of the running amount
  10. modifier 78 present → 70% of the running amount
  11. modifier 80 present → 16% of the running amount
  12. modifier 81 present → 16% of the running amount
  13. modifier 82 present → 16% of the running amount
  14. modifier AS present → 13.6% of the running amount
  15. cap each charge and the account total at 100% of billed charges
HealthScope-2019-01 · no contract map6 base · 15 adj
no contract map — cannot be resolved
Base terms — first match wins
  1. 100% of the HealthScope-Fixed-Fees fee schedule
  2. 100% of the Medicare-HealthScope-DME fee schedule
  3. 100% of the Fixed-Fees-Lab fee schedule
  4. 100% of the Profee-HealthScope-Hospital fee schedule — when PlaceOfServiceCategory Clinic is absent
  5. 100% of the Profee-HealthScope-Clinic fee schedule — when PlaceOfServiceCategory Clinic is present
  6. 70% of billed charges
Adjustments — all apply, in order
  1. modifier 1 present → 0% of the running amount
  2. multiple-endoscopy reduction (contract rules)
  3. multiple-procedure reduction (contract rules) — base codes 2; pays 100/50%
  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. custom SQL — Pays fixed flat dollar amounts for two radiology codes (72141 MRI spine, 72148 MRI lumbar) specifically when billed with the technical-component ('TC') modifier.
  15. cap each charge and the account total at 100% of billed charges
Legacy · no contract map3 base · 16 adj
no contract map — cannot be resolved
Base terms — first match wins
  1. 90% of the WorkersComp-Clinic fee schedule — when PlaceOfServiceCategory Clinic is present; LegacyProviders Contracted is present
  2. 90% of the WorkersComp-Hospital fee schedule — when PlaceOfServiceCategory Clinic is absent; LegacyProviders Contracted is present
  3. 100% of billed charges — when LegacyProviders Contracted is present
Adjustments — all apply, in order
  1. modifier 1 present → 0% of the running amount
  2. multiple-endoscopy reduction (contract rules)
  3. multiple-procedure reduction (contract rules) — base codes 2; pays 100/50%
  4. rescale by a percentage read from the Mid-Level-Charges schedule — when IsMidLevelProvider Yes is present
  5. modifier 22 present → 135% of the running amount
  6. modifier 50 present → 150% of the running amount
  7. modifier 52 present → 50% of the running amount
  8. modifier 54 present → 80% of the running amount
  9. modifier 62 present → 62.5% of the running amount
  10. modifier 78 present → 70% of the running amount
  11. modifier 80 present → 16% of the running amount
  12. modifier 81 present → 16% of the running amount
  13. modifier 82 present → 16% of the running amount
  14. modifier AS present → 13.6% of the running amount
  15. modifier 29 present → 85% of the running amount — when LegacyProviders Contracted is present
  16. cap each charge and the account total at 100% of billed charges
Medicare · no contract map7 base · 18 adj
no contract map — cannot be resolved
Base terms — first match wins
  1. 100% of the Medicare-DME fee schedule
  2. 100% of the Medicare-Lab fee schedule
  3. 100% of the Medicare-Drug fee schedule
  4. 100% of the Fixed-Fees fee schedule
  5. 100% of the Profee-Clinic fee schedule — when PlaceOfServiceCategory Clinic is present
  6. 100% of the Profee-Hospital fee schedule — when PlaceOfServiceCategory Clinic is absent
  7. 100% of billed charges
Adjustments — all apply, in order
  1. custom SQL — Applies the shared CommonData Medicare sequestration reduction to a charge's allowed amount by calling a scalar SQL function, evidently for a plan whose FeeLogic isn't flagged Medicare-based (the engine's automatic MedicareSequestrationAdjustment only fires for Medicare-based FeeLogics).
  2. modifier 1 present → 0% of the running amount
  3. multiple-endoscopy reduction (contract rules)
  4. multiple-procedure reduction (contract rules) — base codes 2; pays 100/50%
  5. multiple-physiotherapy reduction — when PlaceOfServiceCategory Clinic is present
  6. multiple-physiotherapy reduction — when PlaceOfServiceCategory Clinic is absent
  7. rescale by a percentage read from the Mid-Level-Charges schedule — when IsMidLevelProvider Yes is present
  8. modifier 22 present → 135% of the running amount
  9. modifier 50 present → 150% of the running amount
  10. modifier 52 present → 50% of the running amount
  11. modifier 54 present → 80% of the running amount
  12. modifier 62 present → 62.5% of the running amount
  13. modifier 78 present → 70% of the running amount
  14. modifier 80 present → 16% of the running amount
  15. modifier 81 present → 16% of the running amount
  16. modifier 82 present → 16% of the running amount
  17. modifier AS present → 16% of the running amount
  18. cap each charge and the account total at 100% of billed charges
PHCS · no contract map8 base · 15 adj
no contract map — cannot be resolved
Base terms — first match wins
  1. 100% of the WorkersComp-Hospital fee schedule — when PlaceOfServiceCategory Clinic is absent
  2. 85% of the WorkersComp-Clinic fee schedule — when PlaceOfServiceCategory Clinic is present
  3. 100% of the Medicare-DME fee schedule
  4. 134% of the Medicare-Lab fee schedule
  5. 106% of the Medicare-Drug fee schedule
  6. 100% of the Profee-Clinic fee schedule — when PlaceOfServiceCategory Clinic is present
  7. 100% of the Profee-Hospital fee schedule — when PlaceOfServiceCategory Clinic is absent
  8. 70% of billed charges
Adjustments — all apply, in order
  1. modifier 1 present → 0% of the running amount
  2. multiple-endoscopy reduction (contract rules)
  3. multiple-procedure reduction (contract rules) — base codes 2; pays 100/50%
  4. rescale by a percentage read from the Mid-Level-Charges schedule — when IsMidLevelProvider Yes is present
  5. modifier 22 present → 135% of the running amount
  6. modifier 50 present → 150% of the running amount
  7. modifier 52 present → 50% of the running amount
  8. modifier 54 present → 80% of the running amount
  9. modifier 62 present → 62.5% of the running amount
  10. modifier 78 present → 70% of the running amount
  11. modifier 80 present → 16% of the running amount
  12. modifier 81 present → 16% of the running amount
  13. modifier 82 present → 16% of the running amount
  14. modifier AS present → 13.6% of the running amount
  15. cap each charge and the account total at 100% of billed charges
Prominence · no contract map3 base · 3 adj
no contract map — cannot be resolved
Base terms — first match wins
  1. 100% of the Profee-Hospital fee schedule — when PlaceOfServiceCategory Clinic is absent
  2. 100% of the Profee-Clinic fee schedule — when PlaceOfServiceCategory Clinic is present
  3. 60% of billed charges
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. cap each charge and the account total at 100% of billed charges
SilverSummit-2022 · no contract map6 base · 14 adj
no contract map — cannot be resolved
Base terms — first match wins
  1. 100% of the Medicare-Lab fee schedule
  2. 100% of the Medicare-Drug fee schedule
  3. 100% of the Medicare-DME fee schedule
  4. 100% of the Profee-Hospital fee schedule — when PlaceOfServiceCategory Clinic is absent
  5. 100% of the Profee-Clinic fee schedule — when PlaceOfServiceCategory Clinic is present
  6. 100% of billed charges
Adjustments — all apply, in order
  1. modifier 1 present → 0% of the running amount
  2. multiple-endoscopy reduction (contract rules)
  3. multiple-procedure reduction (contract rules) — base codes 2; pays 100/50/25/10/5%
  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
United · no contract map6 base · 15 adj
no contract map — cannot be resolved
Base terms — first match wins
  1. 100% of the Medicare-DME fee schedule
  2. 60% of the Medicare-Lab fee schedule
  3. 100% of the Medicare-Drug fee schedule
  4. 100% of the Profee-Clinic fee schedule — when PlaceOfServiceCategory Clinic is present
  5. 100% of the Profee-Hospital fee schedule — when PlaceOfServiceCategory Clinic is absent
  6. 40% of billed charges
Adjustments — all apply, in order
  1. modifier 1 present → 0% of the running amount
  2. multiple-endoscopy reduction (contract rules)
  3. multiple-procedure reduction (contract rules) — base codes 2; pays 100/50%
  4. rescale by a percentage read from the Mid-Level-Charges schedule — when IsMidLevelProvider Yes is present
  5. modifier 22 present → 135% of the running amount
  6. modifier 50 present → 150% of the running amount
  7. modifier 52 present → 50% of the running amount
  8. modifier 54 present → 80% of the running amount
  9. modifier 62 present → 62.5% of the running amount
  10. modifier 78 present → 70% of the running amount
  11. modifier 80 present → 16% of the running amount
  12. modifier 81 present → 16% of the running amount
  13. modifier 82 present → 16% of the running amount
  14. modifier AS present → 13.6% of the running amount
  15. cap each charge and the account total at 100% of billed charges
United-2022-01-01 · no contract map4 base · 15 adj
no contract map — cannot be resolved
Base terms — first match wins
  1. custom SQL — Medicare-style anesthesia fee: base units for the CPT anesthesia code plus time units (billed units divided into 15-minute increments), times a flat $56 conversion factor -- a simplified anesthesia formula that skips the physical-status modifier add-on and the locality-specific conversion factor the standard MedicareAnesthesia methodology uses.
  2. 100% of the Profee-Hospital fee schedule — when PlaceOfServiceCategory Clinic is absent
  3. 100% of the Profee-Clinic fee schedule — when PlaceOfServiceCategory Clinic is present
  4. 40% of billed charges
Adjustments — all apply, in order
  1. modifier 1 present → 0% of the running amount
  2. multiple-endoscopy reduction (contract rules)
  3. multiple-procedure reduction (contract rules) — base codes 2; pays 100/50%
  4. rescale by a percentage read from the Mid-Level-Charges schedule — when IsMidLevelProvider Yes is present
  5. modifier 22 present → 135% of the running amount
  6. modifier 50 present → 150% of the running amount
  7. modifier 52 present → 50% of the running amount
  8. modifier 54 present → 80% of the running amount
  9. modifier 62 present → 62.5% of the running amount
  10. modifier 78 present → 70% of the running amount
  11. modifier 80 present → 16% of the running amount
  12. modifier 81 present → 16% of the running amount
  13. modifier 82 present → 16% of the running amount
  14. modifier AS present → 13.6% of the running amount
  15. cap each charge and the account total at 100% of billed charges
WC NV · no contract map5 base · 16 adj
no contract map — cannot be resolved
Base terms — first match wins
  1. 100% of the Fixed-Fees fee schedule
  2. 120% of the Medicare-DME fee schedule
  3. 100% of the WorkersComp-Clinic fee schedule — when PlaceOfServiceCategory Clinic is present
  4. 100% of the WorkersComp-Hospital fee schedule — when PlaceOfServiceCategory Clinic is absent
  5. 100% of billed charges
Adjustments — all apply, in order
  1. modifier 1 present → 0% of the running amount
  2. multiple-endoscopy reduction (contract rules)
  3. multiple-procedure reduction (contract rules) — base codes 2; pays 100/50%
  4. rescale by a percentage read from the Mid-Level-Charges schedule — when IsMidLevelProvider Yes is present
  5. modifier 22 present → 135% of the running amount
  6. modifier 50 present → 150% of the running amount
  7. modifier 52 present → 50% of the running amount
  8. modifier 54 present → 80% of the running amount
  9. modifier 62 present → 62.5% of the running amount
  10. modifier 78 present → 70% of the running amount
  11. modifier 80 present → 16% of the running amount
  12. modifier 81 present → 16% of the running amount
  13. modifier 82 present → 16% of the running amount
  14. modifier AS present → 13.6% of the running amount
  15. modifier 29 present → 85% of the running amount
  16. cap each charge and the account total at 100% of billed charges
WC NV SAW · no contract map5 base · 16 adj
no contract map — cannot be resolved
Base terms — first match wins
  1. 100% of the Fixed-Fees fee schedule
  2. 120% of the Medicare-DME fee schedule
  3. 100% of the WorkersComp-Hospital fee schedule — when PlaceOfServiceCategory Clinic is absent
  4. 90% of the WorkersComp-Clinic fee schedule — when PlaceOfServiceCategory Clinic is present
  5. 90% of billed charges
Adjustments — all apply, in order
  1. modifier 1 present → 0% of the running amount
  2. multiple-endoscopy reduction (contract rules)
  3. multiple-procedure reduction (contract rules) — base codes 2; pays 100/50%
  4. rescale by a percentage read from the Mid-Level-Charges schedule — when IsMidLevelProvider Yes is present
  5. modifier 22 present → 135% of the running amount
  6. modifier 50 present → 150% of the running amount
  7. modifier 52 present → 50% of the running amount
  8. modifier 54 present → 80% of the running amount
  9. modifier 62 present → 62.5% of the running amount
  10. modifier 78 present → 70% of the running amount
  11. modifier 80 present → 16% of the running amount
  12. modifier 81 present → 16% of the running amount
  13. modifier 82 present → 16% of the running amount
  14. modifier AS present → 13.6% of the running amount
  15. modifier 29 present → 85% of the running amount
  16. cap each charge and the account total at 100% of billed charges