Fee Schedules
A fee schedule is a reimbursement method where the allowed amount is retrieved from a look-up table (i.e. the fee schedule). A fee schedule line consists of a number of fields that correspond to fields on the claim or claim line, such as the service code, provider.
Fee Schedules Fields
| Field | Description |
|---|---|
Code |
The code of the fee schedule |
Description |
The description of the fee schedule |
Fee schedule type |
The fee schedule type to which the fee schedule belongs |
Modifier usage |
Specifies how the modifier list is evaluated In: When one or more of the modifiers in the list is present on the claim line Not In: When none of the modifiers in the list are present on the claim line |
Line condition |
A common dynamic logic condition that is applied in the evaluation of each fee schedule line |
Modifier evaluation message |
The message that is attached to the claim line if the fee schedule is not applied based on the evaluation of the fee schedule modifiers |
Priced message |
The message that is attached to the claim line if the fee schedule is applied |
Currency |
The currency of the amounts in the fee schedule (all fee schedule lines in the fee schedule that specify an amount will have the same currency) |
Access Restriction |
Determines whether or not the access to the fee schedule is restricted |
A fee schedule can specify one or more modifiers:
Fee Schedule Modifiers
| Field | Description |
|---|---|
Fee schedule |
The fee schedule to which the fee schedule modifier refers |
Modifier |
The modifier to which the fee schedule modifier applies |
The modifier usage (in / not in) must be specified and may only be specified when the fee schedule line specifies one or more modifiers.
The following is a list of the placeholder values for the priced and modifier evaluation messages that are attached to the claim line upon applying a fee schedule:
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The code of the fee schedule
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The description of the fee schedule
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The provider pricing clause quantifier
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Modifier list (fee schedule modifiers for the modifier evaluation message; fee schedule line modifiers for the priced message)
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The description of the fee schedule type
A fee schedule type specifies how the fee schedule line amounts are interpreted, i.e., amount per unit or amount for all units. Some pricing rules may refer to a fee schedule type. If a fee schedule type is specified on a pricing rule then the rule is only applied if a fee schedule of that type has been applied (in combination with an 'In' usage) or has not been applied (in combination with a 'Not In' usage) to calculate the price on the claim line.
Fee Schedule Types
| Field | Description |
|---|---|
Code |
The code of the fee schedule type |
Description |
The description of the fee schedule type |
Calculation type |
Specifies if the fee schedule applies a flat rate or an amount per unit |
A fee schedule has zero, one or more fee schedule lines. A fee schedule line has either an amount or a percentage and refers to one or more procedures and/or procedure groups to which the amount/percentage applies. A fee schedule line can be particularized to one or more claim line modifiers. For provider or contract specific agreements, fee schedule lines can be particularized to a provider (individual and/or organization), provider group and/or contract reference.
Fee Schedule Lines
| Field | Description |
|---|---|
Fee schedule |
The fee schedule to which the line refers |
Procedure |
The procedure to which the fee schedule line applies |
Procedure group |
The procedure group to which the fee schedule line applies |
Procedure 2 |
The second procedure to which the fee schedule line applies |
Procedure group 2 |
The second procedure group to which the fee schedule line applies |
Procedure 3 |
The third procedure to which the fee schedule line applies |
Procedure group 3 |
The third procedure group to which the fee schedule line applies |
Classification usage |
How should the classification list be evaluated? In: When one of the classifications in the list is present on the claim line Not In: When none of the classifications in the list are present on the claim line |
Individual provider |
The individual provider to which the fee schedule line applies |
Organization provider |
The organization provider to which the fee schedule line applies |
Provider group |
The provider group to which the fee schedule line applies |
Contract reference |
The contract reference to which the fee schedule line applies |
Amount |
The amount that is applied to each allowed unit as the basis for the allowed amount |
Currency |
The currency of the amount (it will automatically be set to the currency that is specified on the fee schedule if an amount is specified) |
Percentage |
The percentage that is applied to the claimed amount of the claim line as the basis for the allowed amount |
Start date |
The start date of the period for which the fee schedule line will be applied |
End date |
The end date of the period for which the fee schedule line will be applied |
Enabled? |
Is the fee schedule line enabled? |
Constraints:
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Either the amount or the percentage must be specified
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One or more procedures and/or procedure groups of a fee schedule line must be specified
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A fee schedule line may only refer to a provider group if it does not also refer to an individual and/or organization provider
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The classification usage must be specified when a classification list is used and may not be specified when a classification list is not used
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Within a fee schedule, enabled lines that are functionally the same may not overlap in time validity
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Fee schedule lines are functionally the same if they have the same:
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Procedures
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Procedure Groups
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Individual Provider
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Organization Provider
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Provider Group
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Contract Reference
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Modifiers
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Classifications and Classification Usage
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Certain Dynamic Fields
Which dynamic fields are part of the check is specified in the dynamic logic function with signature Fee Schedule Line Duplicity (this function returns a list of dynamic field usage names)
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A fee schedule line can refer to one or more modifiers: